Progestational Agents

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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
71225010501 HYDROXYPROGESTERONE CAPROATE hydroxyprogesterone caproat/PF VIAL 250 mg/mL (1 mL) N Y N  
71225010401 HYDROXYPROGESTERONE CAPROATE hydroxyprogesterone caproate VIAL 250 mg/mL N Y N  
00555077902 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 10 mg Y Y N  
00555077904 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 10 mg Y Y N  
59762005601 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 10 mg Y Y N  
59762005602 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 10 mg Y Y N  
60687010511 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 10 mg Y Y N  
60687010521 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 10 mg Y Y N  
00009005101 PROVERA medroxyprogesterone acetate TABLET 10 mg Y Y N  
00555087202 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 2.5 mg Y Y N  
00555087204 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 2.5 mg Y Y N  
59762005501 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 2.5 mg Y Y N  
59762005502 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 2.5 mg Y Y N  
00009006412 PROVERA medroxyprogesterone acetate TABLET 2.5 mg Y Y N  
00555087302 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 5 mg Y Y N  
00555087304 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 5 mg Y Y N  
59762005801 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 5 mg Y Y N  
59762005802 MEDROXYPROGESTERONE ACETATE medroxyprogesterone acetate TABLET 5 mg Y Y N  
00009028701 PROVERA medroxyprogesterone acetate TABLET 5 mg Y Y N  
70700032650 GALLIFREY norethindrone acetate TABLET 5 mg Y Y N  
00378729189 NORETHINDRONE ACETATE norethindrone acetate TABLET 5 mg Y Y N  
00555021110 NORETHINDRONE ACETATE norethindrone acetate TABLET 5 mg Y Y N  
50742026750 NORETHINDRONE ACETATE norethindrone acetate TABLET 5 mg Y Y N  
65162047505 NORETHINDRONE ACETATE norethindrone acetate TABLET 5 mg Y Y N  
65162047509 NORETHINDRONE ACETATE norethindrone acetate TABLET 5 mg Y Y N  
65862071550 NORETHINDRONE ACETATE norethindrone acetate TABLET 5 mg Y Y N  
68462030450 NORETHINDRONE ACETATE norethindrone acetate TABLET 5 mg Y Y N  
00143972501 PROGESTERONE progesterone VIAL 50 mg/mL N Y N  
00591312879 PROGESTERONE progesterone VIAL 50 mg/mL N Y N  
55150030610 PROGESTERONE progesterone VIAL 50 mg/mL N Y N  
63323026110 PROGESTERONE progesterone VIAL 50 mg/mL N Y N  
70700028622 PROGESTERONE progesterone VIAL 50 mg/mL N Y N  
16714015701 PROGESTERONE progesterone, micronized CAPSULE 100 mg Y Y N  
43598034901 PROGESTERONE progesterone, micronized CAPSULE 100 mg Y Y N  
59651015201 PROGESTERONE progesterone, micronized CAPSULE 100 mg Y Y N  
65162080710 PROGESTERONE progesterone, micronized CAPSULE 100 mg Y Y N  
69452023320 PROGESTERONE progesterone, micronized CAPSULE 100 mg Y Y N  
69543037410 PROGESTERONE progesterone, micronized CAPSULE 100 mg Y Y N  
70700016201 PROGESTERONE progesterone, micronized CAPSULE 100 mg Y Y N  
72989037230 PROMETRIUM progesterone, micronized CAPSULE 100 mg Y Y N  
16714015801 PROGESTERONE progesterone, micronized CAPSULE 200 mg Y Y N  
59651015301 PROGESTERONE progesterone, micronized CAPSULE 200 mg Y Y N  
65162080810 PROGESTERONE progesterone, micronized CAPSULE 200 mg Y Y N  
69452023420 PROGESTERONE progesterone, micronized CAPSULE 200 mg Y Y N  
69543037510 PROGESTERONE progesterone, micronized CAPSULE 200 mg Y Y N  
70700016301 PROGESTERONE progesterone, micronized CAPSULE 200 mg Y Y N  
72989037330 PROMETRIUM progesterone, micronized CAPSULE 200 mg Y Y N  
00023615004 CRINONE progesterone, micronized GEL/PF APP 4 % N Y N  
00023615005 CRINONE progesterone, micronized GEL/PF APP 4 % N Y N  
00023615108 CRINONE progesterone, micronized GEL/PF APP 8 % N Y N  
00023615109 CRINONE progesterone, micronized GEL/PF APP 8 % N Y N  
55566650001 ENDOMETRIN progesterone, micronized INSERT 100 mg N Y N  
55566650002 ENDOMETRIN progesterone, micronized INSERT 100 mg N Y N  
55566650003 ENDOMETRIN progesterone, micronized INSERT 100 mg N Y N  
70700020170 PROGESTERONE progesterone, micronized INSERT 100 mg N Y N  
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