Pharmacy Help Desk: 1-877-209-1264, Provider PA Help Desk: 1-877-207-1126

Preferred Drug List

File Description Date
PDL Effective 05-24-23 590.09 KB 2023/05/22
PDL Effective 05-05-23 590.02 KB 2023/05/04
PDL Effective 03-22-23 592.16 KB 2023/03/14
PDL Effective 01-20-23 599.32 KB 2023/01/20
PDL Effective 01-01-23 599.17 KB 2022/12/23
PDL Effective 11-30-22 593.12 KB 2022/11/30
PDL Effective 11-04-22 603.9 KB 2022/11/04
PDL Effective 09-16-22 594.92 KB 2022/09/16
PDL Effective 06-08-22 584.1 KB 2022/06/08
PDL Effective 04-11-22 581.42 KB 2022/04/11
PDL Effective 03-30-22 581.19 KB 2022/03/30
PDL Effective 03-21-22 585.37 KB 2022/03/22
PDL Effective 01-01-22 573.78 KB 2021/12/31
PDL Effective 10-18-21 578.17 KB 2021/10/18
PDL Effective 06-16-21 569.03 KB 2021/06/16
PDL Effective 02-24-21 575.38 KB 2021/02/22
PDL Effective 01-01-21 415.33 KB 2020/12/31
PDL Effective 10-08-20 565.73 KB 2020/10/08
PDL Effective 08-10-20 575.83 KB 2020/08/10
PDL Effective 02-26-20 576.79 KB 2020/03/03
PDL Effective 01-01-20 410.72 KB 2019/12/31
PDL Effective 11-01-19 566.84 KB 2019/11/04
PDL Effective 09-18-19 565.47 KB 2019/09/18
PDL Effective 07-10-19 563.97 KB 2019/07/11
PDL Effective 04-25-19 402.5 KB 2019/04/26
PDL Effective 3-12-19 552.75 KB 2019/03/12
PDL Effective 01-01-19 845.79 KB 2018/12/31
PDL Effective 9-27-18 832.81 KB 2018/09/27
PDL Effective 07-17-18 828.95 KB 2018/07/18
PDL Effective 04-11-18 686.39 KB 2018/04/13
PDL Effective 3-14-18 686.29 KB 2018/03/14
PDL Effective 1-24-18 680.41 KB 2018/01/25
PDL Effective 1-1-18 539.02 KB 2018/01/02
PDL Effective 9-29-17 680.72 KB 2017/09/29
PDL Effective 5-30-17 581.36 KB 2017/05/30
PDL Effective 4-7-2017 579.67 KB 2017/04/07
PDL Effective 01-01-17 642.36 KB 2016/12/22
PDL Effective 8-31-16 640.81 KB 2016/09/01
PDL Effective 7-5-16 636.99 KB 2016/07/05
PDL Effective 4-6-16 755.78 KB 2016/04/01
PDL Effective 01-11-16 599.17 KB 2016/01/11
PDL Effective January 1, 2016 564.91 KB 2015/12/29
PDL Effective 12-02-15 623.14 KB 2015/12/02
PDL Effective 10-15-15 622.71 KB 2015/10/15
PDL Effective 8-19-15 592.25 KB 2015/08/19
PDL Effective 7-1-5 564.52 KB 2015/07/02
PDL Effective 6-1-15 564.09 KB 2015/06/23
PDL Effective 4-22-15 563.45 KB 2015/04/22
PDL Effective 2-25-15 561.76 KB 2015/02/25
PDL Effective 1-1-15 630.98 KB 2015/01/01
PDL Effective 10-15-14 325.84 KB 2014/10/15
PDL Effective 8-6-14 444.75 KB 2014/08/06
PDL Effective 7-1-14 410.34 KB 2014/07/01
PDL Effective 5-22-2014 423.79 KB 2014/05/22
PDL Effective 3-5-2014 410.14 KB 2014/03/05
PDL Effective 01-08-2014 425.75 KB 2014/01/08
PDL Effective 01-01-2014 480.36 KB 2013/12/30
PDL Effective 11-01-2013 612.31 KB 2013/11/07
PDL Effective 9-10-2013 245.08 KB 2013/09/12
PDL Effective 5-28-2013 645.46 KB 2013/05/28
PDL Effective 1-1-2013 490.24 KB 2013/01/03
PDL Effective 8-1-2012 142.54 KB 2012/08/30
PDL Effective 5-2-2012 145.72 KB 2012/05/14
PDL Effective 4-18-2012 195.88 KB 2012/04/25
PDL Effective 01-01-12 178.23 KB 2012/01/04

Prior Authorization Process

File Description Date
Website PA Process 167.99 KB 2010/08/06

Additional PDL News & Info

File Description Date
Additional Therapeutic Criteria Effective June 2015 52.72 KB 2013/10/16
Dosage Limitation Chart (June 2011) 62.84 KB 2011/06/15

Archive Files