Immunosuppressants

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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 but eligible patients will encounter a co-pay at the pharmacy.
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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
AZATHIOPRINE AZATHIOPRINE TABLET Y    
AZATHIOPRINE IMURAN TABLET Y    
CYCLOSPORINE CYCLOSPORINE CAPSULE Y    
CYCLOSPORINE SANDIMMUNE CAPSULE Y    
CYCLOSPORINE SANDIMMUNE SOLUTION Y    
CYCLOSPORINE, MODIFIED GENGRAF CAPSULE Y    
CYCLOSPORINE, MODIFIED NEORAL CAPSULE Y    
CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED CAPSULE Y    
CYCLOSPORINE, MODIFIED CYCLOSPORINE SOLUTION Y    
CYCLOSPORINE, MODIFIED GENGRAF SOLUTION Y    
CYCLOSPORINE, MODIFIED NEORAL SOLUTION Y    
EVEROLIMUS ZORTRESS TABLET Y    
MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL CAPSULE Y    
MYCOPHENOLATE MOFETIL CELLCEPT CAPSULE Y    
MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL SUSP RECON Y    
MYCOPHENOLATE MOFETIL CELLCEPT SUSP RECON Y    
MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL TABLET Y    
MYCOPHENOLATE MOFETIL CELLCEPT TABLET Y    
MYCOPHENOLATE SODIUM MYFORTIC TABLET DR Y    
MYCOPHENOLATE SODIUM MYCOPHENOLIC ACID TABLET DR Y    
SIROLIMUS RAPAMUNE SOLUTION Y    
SIROLIMUS SIROLIMUS TABLET Y    
SIROLIMUS RAPAMUNE TABLET Y    
TACROLIMUS TACROLIMUS CAPSULE Y    
TACROLIMUS PROGRAF CAPSULE Y    
AZATHIOPRINE AZASAN TABLET N    
TACROLIMUS ASTAGRAF XL CAP ER 24H N    
TACROLIMUS ENVARSUS XR TAB ER 24H N