Digitalis Preps
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 |
|---|---|---|---|---|---|---|---|---|
| 70515026210 | LANOXIN PEDIATRIC | digoxin | AMPUL | 100 mcg/mL (0.1 mg/mL) | Y | N | ||
| 00641141031 | DIGOXIN | digoxin | AMPUL | 250 mcg/mL (0.25 mg/mL) | Y | N | ||
| 00641141035 | DIGOXIN | digoxin | AMPUL | 250 mcg/mL (0.25 mg/mL) | Y | N | ||
| 00641618401 | DIGOXIN | digoxin | AMPUL | 250 mcg/mL (0.25 mg/mL) | Y | N | ||
| 00641618425 | DIGOXIN | digoxin | AMPUL | 250 mcg/mL (0.25 mg/mL) | Y | N | ||
| 00781305972 | DIGOXIN | digoxin | AMPUL | 250 mcg/mL (0.25 mg/mL) | Y | N | ||
| 00781305995 | DIGOXIN | digoxin | AMPUL | 250 mcg/mL (0.25 mg/mL) | Y | N | ||
| 70515026010 | LANOXIN | digoxin | AMPUL | 250 mcg/mL (0.25 mg/mL) | Y | N | ||
| 00054005746 | DIGOXIN | digoxin | SOLUTION | 50 mcg/mL (0.05 mg/mL) | Y | N | ||
| 66689032702 | DIGOXIN | digoxin | SOLUTION | 50 mcg/mL (0.05 mg/mL) | Y | N | ||
| 69292060560 | DIGOXIN | digoxin | SOLUTION | 50 mcg/mL (0.05 mg/mL) | Y | N | ||
| 00074216901 | DIGOXIN | digoxin | SYRINGE | 250 mcg/mL (0.25 mg/mL) | Y | N | ||
| 00143124001 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 00143124010 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 00904592161 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 16714059001 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 50268023811 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 50268023815 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 51285091602 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 51285091605 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 57664043718 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 57664043788 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 59651043701 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 59651043799 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 60687085801 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 60687085811 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 62584024201 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 62584024233 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 69238199101 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 69238199107 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 70954020110 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 70954020120 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 82685020101 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 82685020110 | DIGOXIN | digoxin | TABLET | 125 mcg (0.125 mg) | Y | N | ||
| 51079094623 | DIGITEK | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 00143124101 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 00143124110 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 00904592261 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 16714059101 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 51285091502 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 51285091505 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 57664044118 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 57664044188 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 59651043801 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 59651043899 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 60687055101 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 60687055111 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 60687086901 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 60687086911 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 62584024933 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 69238199201 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 69238199207 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 70954020210 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 70954020220 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 82685020201 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 82685020210 | DIGOXIN | digoxin | TABLET | 250 mcg (0.25 mg) | Y | N | ||
| 59651043601 | DIGOXIN | digoxin | TABLET | 62.5 mcg (0.0625 mg) | Y | N | ||
| 70954020010 | DIGOXIN | digoxin | TABLET | 62.5 mcg (0.0625 mg) | Y | N | ||
| 70515026310 | LANOXIN PEDIATRIC | digoxin | VIAL | 100 mcg/mL (0.1 mg/mL) | Y | N | ||
| 70515026110 | LANOXIN | digoxin | VIAL | 500 mcg/2 mL (250 mcg/mL) (0.5 mg/2 mL) (0.25 mg/mL) | Y | N |