Oxytocics

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00009085605 HEMABATE carboprost tromethamine AMPUL 250 mcg/mL Y N  
00009085608 HEMABATE carboprost tromethamine AMPUL 250 mcg/mL Y N  
43598017910 CARBOPROST TROMETHAMINE carboprost tromethamine SYRINGE 250 mcg/mL Y N  
43598017911 CARBOPROST TROMETHAMINE carboprost tromethamine SYRINGE 250 mcg/mL Y N  
00409006401 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
00409006410 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
43598069811 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
43598069858 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
43598091711 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
43598091758 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
43598091911 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
43598091958 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
55150045901 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
55150045910 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
62332077701 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
62332077710 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
65145013201 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
65145013210 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
65219057900 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
65219057901 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
70121168001 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
70121168007 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
70512085901 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
70512085905 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
70594011201 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
70594011202 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
71839013701 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
71839013710 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
81298501001 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
81298501003 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
81298501005 CARBOPROST TROMETHAMINE carboprost tromethamine VIAL 250 mcg/mL Y N  
00009335901 PREPIDIL dinoprostone GEL/PF APP 0.5 mg/3 gram Y N  
55566280000 CERVIDIL dinoprostone INSERT ER 10 mg Y N  
55566280001 CERVIDIL dinoprostone INSERT ER 10 mg Y N  
51991014417 METHYLERGONOVINE MALEATE methylergonovine maleate AMPUL 0.2 mg/mL (1 mL) Y N  
51991014499 METHYLERGONOVINE MALEATE methylergonovine maleate AMPUL 0.2 mg/mL (1 mL) Y N  
63704000401 METHYLERGONOVINE MALEATE methylergonovine maleate AMPUL 0.2 mg/mL (1 mL) Y N  
00054063905 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
00054063913 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
00093365522 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
00093365528 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
00904728210 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
16571073521 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
16571073528 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
60687081311 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
60687081394 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
69238160502 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
69238160508 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
70010078612 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
70010078628 METHYLERGONOVINE MALEATE methylergonovine maleate TABLET 0.2 mg Y N  
00517074001 METHYLERGONOVINE MALEATE methylergonovine maleate VIAL 0.2 mg/mL (1 mL) Y N  
00517074020 METHYLERGONOVINE MALEATE methylergonovine maleate VIAL 0.2 mg/mL (1 mL) Y N  
60793041601 OXYTOCIN oxytocin AMPUL 10 unit/mL Y N  
60793041603 OXYTOCIN oxytocin SYRINGE 10 unit/mL Y N  
60793041605 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
60793041606 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
63323001202 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
63323001203 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
63323001206 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
63323001207 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
63323001210 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
63323001211 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
63323001217 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
63323001230 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
65219002100 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
65219002101 OXYTOCIN oxytocin VIAL 10 unit/mL Y N  
42023011602 PITOCIN oxytocin VIAL 10 unit/mL Y N  
42023011625 PITOCIN oxytocin VIAL 10 unit/mL Y N  
42023011673 PITOCIN oxytocin VIAL 10 unit/mL Y N  
42023011683 PITOCIN oxytocin VIAL 10 unit/mL Y N  
42023011693 PITOCIN oxytocin VIAL 10 unit/mL Y N  
42023013006 PITOCIN oxytocin VIAL 10 unit/mL Y N  
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