Inflammatory Bowel Disease

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PDL Reference Documents

PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00054007928 BALSALAZIDE DISODIUM balsalazide disodium CAPSULE 750 mg Y Y N  
50268010211 BALSALAZIDE DISODIUM balsalazide disodium CAPSULE 750 mg Y Y N  
50268010213 BALSALAZIDE DISODIUM balsalazide disodium CAPSULE 750 mg Y Y N  
60505257507 BALSALAZIDE DISODIUM balsalazide disodium CAPSULE 750 mg Y Y N  
70710162601 BALSALAZIDE DISODIUM balsalazide disodium CAPSULE 750 mg Y Y N  
80005012625 BALSALAZIDE DISODIUM balsalazide disodium CAPSULE 750 mg Y Y N  
00574985510 BUDESONIDE DR budesonide CAPDR - ER 3 mg Y Y N  
00904731310 BUDESONIDE DR budesonide CAPDR - ER 3 mg Y Y N  
16714082901 BUDESONIDE DR budesonide CAPDR - ER 3 mg Y Y N  
60687059632 BUDESONIDE DR budesonide CAPDR - ER 3 mg Y Y N  
60687059633 BUDESONIDE DR budesonide CAPDR - ER 3 mg Y Y N  
68382072001 BUDESONIDE DR budesonide CAPDR - ER 3 mg Y Y N  
51862058001 BUDESONIDE EC budesonide CAPDR - ER 3 mg Y Y N  
65162077810 BUDESONIDE EC budesonide CAPDR - ER 3 mg Y Y N  
45802062701 BUDESONIDE budesonide FOAM/APPL 2 mg/actuation N Y N  
45802062786 BUDESONIDE budesonide FOAM/APPL 2 mg/actuation N Y N  
00378450093 BUDESONIDE ER budesonide TABDR - ER 9 mg N Y N  
00591251030 BUDESONIDE ER budesonide TABDR - ER 9 mg N Y N  
00093922489 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
00378137578 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
00832605612 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
50268057711 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
50268057715 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
59651039708 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
60687065032 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
60687065033 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
62332072435 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
67877071712 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
68382045219 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
70748021416 MESALAMINE ER mesalamine CAP ER 24H 0.375 gram Y Y N  
00093590786 MESALAMINE DR mesalamine CAP(DRTAB) 400 mg N Y N  
59762011701 MESALAMINE DR mesalamine CAP(DRTAB) 400 mg N Y N  
60687055632 MESALAMINE DR mesalamine CAP(DRTAB) 400 mg N Y N  
60687055633 MESALAMINE DR mesalamine CAP(DRTAB) 400 mg N Y N  
54092018981 PENTASA mesalamine CAPSULE ER 250 mg N Y N  
63304008913 MESALAMINE ER mesalamine CAPSULE ER 500 mg N Y N  
54092019112 PENTASA mesalamine CAPSULE ER 500 mg N Y N  
21922004501 MESALAMINE mesalamine ENEMA 4 gram/60 mL N Y N  
21922004547 MESALAMINE mesalamine ENEMA 4 gram/60 mL N Y N  
21922004549 MESALAMINE mesalamine ENEMA 4 gram/60 mL N Y N  
45802009828 MESALAMINE mesalamine ENEMA 4 gram/60 mL N Y N  
45802009846 MESALAMINE mesalamine ENEMA 4 gram/60 mL N Y N  
45802009851 MESALAMINE mesalamine ENEMA 4 gram/60 mL N Y N  
62559042007 MESALAMINE mesalamine ENEMA 4 gram/60 mL N Y N  
62559042011 MESALAMINE mesalamine ENEMA 4 gram/60 mL N Y N  
00037006606 ROWASA mesalamine ENEMA 4 gram/60 mL N Y N  
00037002207 SFROWASA mesalamine ENEMA 4 gram/60 mL N Y N  
00037002228 SFROWASA mesalamine ENEMA 4 gram/60 mL N Y N  
00037002260 SFROWASA mesalamine ENEMA 4 gram/60 mL N Y N  
58914050156 CANASA mesalamine SUPP.RECT 1,000 mg Y Y N  
00472191501 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
00472191530 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
16571024603 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
16571024616 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
16714024501 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
16714024530 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
31722000530 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
31722000532 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
59762011801 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
59762011803 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
64980028203 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
69918056030 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
70710130206 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
70710130207 MESALAMINE mesalamine SUPP.RECT 1,000 mg Y Y N  
54092047601 LIALDA mesalamine TABLET DR 1.2 gram Y Y N  
54092047602 LIALDA mesalamine TABLET DR 1.2 gram Y Y N  
54092047612 LIALDA mesalamine TABLET DR 1.2 gram Y Y N  
00527301248 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
00591224522 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
00904683204 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
16714083001 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
31722004312 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
54092010001 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
60687039725 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
60687039795 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
62135071412 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
62135071460 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
63304017513 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
68382071119 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
72603030401 MESALAMINE mesalamine TABLET DR 1.2 gram Y Y N  
00480775080 MESALAMINE mesalamine TABLET DR 800 mg Y Y N  
60687040825 MESALAMINE mesalamine TABLET DR 800 mg Y Y N  
60687040895 MESALAMINE mesalamine TABLET DR 800 mg Y Y N  
65162036018 MESALAMINE mesalamine TABLET DR 800 mg Y Y N  
68382043528 MESALAMINE mesalamine TABLET DR 800 mg Y Y N  
45802092341 MESALAMINE mesalamine w/cleansing wipes ENEMA KIT 4 gram/60 mL N Y N  
45802092949 MESALAMINE mesalamine w/cleansing wipes ENEMA KIT 4 gram/60 mL N Y N  
00037006603 ROWASA mesalamine w/cleansing wipes ENEMA KIT 4 gram/60 mL N Y N  
00037006605 ROWASA mesalamine w/cleansing wipes ENEMA KIT 4 gram/60 mL N Y N  
00037686010 DIPENTUM olsalazine sodium CAPSULE 250 mg Y Y N  
00013010110 AZULFIDINE sulfasalazine TABLET 500 mg Y Y N  
00013010130 AZULFIDINE sulfasalazine TABLET 500 mg Y Y N  
00093323401 SULFASALAZINE sulfasalazine TABLET 500 mg Y Y N  
00093323405 SULFASALAZINE sulfasalazine TABLET 500 mg Y Y N  
00093323410 SULFASALAZINE sulfasalazine TABLET 500 mg Y Y N  
23155001901 SULFASALAZINE sulfasalazine TABLET 500 mg Y Y N  
59762500005 SULFASALAZINE sulfasalazine TABLET 500 mg Y Y N  
59762500006 SULFASALAZINE sulfasalazine TABLET 500 mg Y Y N  
62135096001 SULFASALAZINE sulfasalazine TABLET 500 mg Y Y N  
62135096005 SULFASALAZINE sulfasalazine TABLET 500 mg Y Y N  
62135096010 SULFASALAZINE sulfasalazine TABLET 500 mg Y Y N  
62135096031 SULFASALAZINE sulfasalazine TABLET 500 mg Y Y N  
00013010250 AZULFIDINE sulfasalazine TABLET DR 500 mg Y Y N  
00013010260 AZULFIDINE sulfasalazine TABLET DR 500 mg Y Y N  
00254590528 SULFASALAZINE sulfasalazine TABLET DR 500 mg Y Y N  
59762010405 SULFASALAZINE DR sulfasalazine TABLET DR 500 mg Y Y N  
59762010406 SULFASALAZINE DR sulfasalazine TABLET DR 500 mg Y Y N  
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