Diabetes, Sulfonylureas
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 50111037306 | CHLORPROPAMIDE | chlorpropamide | TABLET | 250 mg | N | Y | |
| 16571077301 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 16571077350 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 16729000116 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 42571010001 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 43547039410 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 43547039450 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 50268035811 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 50268035815 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 55111032001 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 55111032005 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 61442011501 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 61442011505 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 68001058400 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 68001058403 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 68084078825 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 68084078895 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 71921021401 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 71921021450 | GLIMEPIRIDE | glimepiride | TABLET | 1 mg | Y | Y | |
| 16571077401 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 16571077450 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 16729000201 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 16729000216 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 42571010101 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 43547039510 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 43547039550 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 50268035911 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 50268035915 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 55111032101 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 55111032105 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 61442011601 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 61442011605 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 68001058500 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 68001058503 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 68084032601 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 68084032611 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 68645057290 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 71921021501 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 71921021550 | GLIMEPIRIDE | glimepiride | TABLET | 2 mg | Y | Y | |
| 72336064101 | GLIMEPIRIDE | glimepiride | TABLET | 3 mg | N | Y | |
| 16571077501 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 16571077550 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 16729000316 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 42571010301 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 42571010305 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 43547039610 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 43547039650 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 50268036011 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 50268036015 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 55111032201 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 55111032205 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 61442011701 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 61442011705 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 68001058600 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 68001058603 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 68084032701 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 68084032711 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 68645057390 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 69543012510 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 71921021601 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 71921021650 | GLIMEPIRIDE | glimepiride | TABLET | 4 mg | Y | Y | |
| 16714089601 | GLIPIZIDE ER | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 16714089602 | GLIPIZIDE ER | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 59651027001 | GLIPIZIDE ER | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 59651027005 | GLIPIZIDE ER | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 59651078201 | GLIPIZIDE ER | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 59651078205 | GLIPIZIDE ER | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 64980028101 | GLIPIZIDE ER | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 64980028105 | GLIPIZIDE ER | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 64980028110 | GLIPIZIDE ER | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 65862089001 | GLIPIZIDE ER | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 59762054202 | GLIPIZIDE XL | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 00049017807 | GLUCOTROL XL | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 00049017808 | GLUCOTROL XL | glipizide | TAB ER 24 | 10 mg | N | Y | |
| 00591090030 | GLIPIZIDE ER | glipizide | TAB ER 24 | 2.5 mg | N | Y | |
| 16714089401 | GLIPIZIDE ER | glipizide | TAB ER 24 | 2.5 mg | N | Y | |
| 59651026830 | GLIPIZIDE ER | glipizide | TAB ER 24 | 2.5 mg | N | Y | |
| 59651078030 | GLIPIZIDE ER | glipizide | TAB ER 24 | 2.5 mg | N | Y | |
| 60687076811 | GLIPIZIDE ER | glipizide | TAB ER 24 | 2.5 mg | N | Y | |
| 60687076821 | GLIPIZIDE ER | glipizide | TAB ER 24 | 2.5 mg | N | Y | |
| 64980027903 | GLIPIZIDE ER | glipizide | TAB ER 24 | 2.5 mg | N | Y | |
| 65862088830 | GLIPIZIDE ER | glipizide | TAB ER 24 | 2.5 mg | N | Y | |
| 00591084401 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 00591084410 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 16714089501 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 16714089502 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 59651026901 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 59651026905 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 59651078101 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 59651078105 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 60687088101 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 60687088111 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 64980028001 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 64980028005 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 64980028010 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 65862088901 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 65862088905 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 68084011101 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 68084011111 | GLIPIZIDE ER | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 00049017402 | GLUCOTROL XL | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 00049017403 | GLUCOTROL XL | glipizide | TAB ER 24 | 5 mg | N | Y | |
| 00591046101 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 00591046105 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 00591046110 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 50268036211 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 50268036215 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 60505014200 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 60505014201 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 60505014202 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 60505014204 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 60687070101 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 60687070111 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 60951071470 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 60951071485 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 62559031610 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 62584071733 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 68645057559 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 69584031010 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 69584031050 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 69584031090 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 72888011700 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 72888011701 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 72888011705 | GLIPIZIDE | glipizide | TABLET | 10 mg | Y | Y | |
| 52817038510 | GLIPIZIDE | glipizide | TABLET | 2.5 mg | N | Y | |
| 00591046001 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 00591046005 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 00591046010 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 00904663761 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 50268036111 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 50268036115 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 60505014100 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 60505014101 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 60505014102 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 60505014108 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 60687069001 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 60687069011 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 62559031510 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 62584071601 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 62584071633 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 68645057454 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 69584030910 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 69584030950 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 69584030990 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 72888011600 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 72888011601 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 72888011605 | GLIPIZIDE | glipizide | TABLET | 5 mg | Y | Y | |
| 00093834201 | GLYBURIDE | glyburide | TABLET | 1.25 mg | Y | Y | |
| 00093947753 | GLYBURIDE | glyburide | TABLET | 1.25 mg | Y | Y | |
| 23155005601 | GLYBURIDE | glyburide | TABLET | 1.25 mg | Y | Y | |
| 62135058330 | GLYBURIDE | glyburide | TABLET | 1.25 mg | Y | Y | |
| 72241003805 | GLYBURIDE | glyburide | TABLET | 1.25 mg | Y | Y | |
| 75834020200 | GLYBURIDE | glyburide | TABLET | 1.25 mg | Y | Y | |
| 00093834301 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 00093834305 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 00093834310 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 00093834398 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 00093943301 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 23155005701 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 62135058430 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 62584071801 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 72241003905 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 72241003910 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 72241003911 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 75834020300 | GLYBURIDE | glyburide | TABLET | 2.5 mg | Y | Y | |
| 00093834401 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 00093834405 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 00093834410 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 00093834498 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 00093936401 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 00093936405 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 00093936410 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 23155005801 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 23155005810 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 59762372703 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 62135058590 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 62584071901 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 62584071933 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 72241004005 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 72241004010 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 72241004011 | GLYBURIDE | glyburide | TABLET | 5 mg | Y | Y | |
| 00093803401 | GLYBURIDE MICRONIZED | glyburide,micronized | TABLET | 1.5 mg | N | Y | |
| 00093803501 | GLYBURIDE MICRONIZED | glyburide,micronized | TABLET | 3 mg | N | Y | |
| 00093803505 | GLYBURIDE MICRONIZED | glyburide,micronized | TABLET | 3 mg | N | Y | |
| 00093803601 | GLYBURIDE MICRONIZED | glyburide,micronized | TABLET | 6 mg | N | Y |