Contraceptives, Systemic
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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 |
|---|---|---|---|---|---|---|---|---|
| 00548540000 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 00548540025 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 55150032901 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 55150032925 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 60219146701 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 60219146702 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 66993037025 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 66993037083 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 67457088700 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 67457088701 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 67457088799 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 70121146702 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 70121146705 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 70700031522 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 70700031525 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y | |||
| 70700031527 | MEDROXYPROGESTERONE ACETATE | medroxyprogesterone acetate | VIAL | 150 mg/mL | Y |