Lipotropics
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 |
|---|---|---|---|---|---|---|---|
| 00904529252 | CHONDROITIN SULFATE | chondroitin sulfate A | CAPSULE | 250 mg | Y | ||
| 00904316372 | LECITHIN | lecithin | CAPSULE | 1,200 mg | Y | ||
| 00904268660 | LECITHIN | lecithin | CAPSULE | 520 mg | Y | ||
| 00904430113 | FISH OIL | omega-3 fatty acids | CAPSULE | Y | |||
| 24385058472 | FISH OIL | omega-3 fatty acids/fish oil | CAPSULE DR | 435 mg-880 mg | Y | ||
| 50268030811 | FISH OIL | omega-3/dha/epa/fish oil | CAPSULE | 1,000 mg (120 mg-180 mg) | Y | PA Document | |
| 50268030815 | FISH OIL | omega-3/dha/epa/fish oil | CAPSULE | 1,000 mg (120 mg-180 mg) | Y | PA Document | |
| 00904723860 | FISH OIL OMEGA-3 | omega-3/dha/epa/fish oil | CAPSULE | 300 mg (120 mg-180 mg)-1,000 mg | Y | ||
| 00904560413 | FISH OIL | omega-3/dha/epa/fish oil | CAPSULE | 60 mg-90 mg-500 mg | Y | PA Document | |
| 00904731813 | FISH OIL | omega-3/dha/epa/fish oil | CAPSULE | 60 mg-90 mg-500 mg | Y | PA Document | |
| 00904750313 | FISH OIL | omega-3/dha/epa/fish oil | CAPSULE | 60 mg-90 mg-500 mg | Y | PA Document |