Mineralocorticoids
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 | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 00115703301 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 00115703302 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 00904731706 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 00904731761 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 50268033011 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 50268033015 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 68084028801 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 68084028811 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 68084028865 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 70954025220 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 70954025230 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 72578016401 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 72578016405 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N | ||
| 72603017001 | FLUDROCORTISONE ACETATE | fludrocortisone acetate | TABLET | 0.1 mg | Y | N |