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 CYCLOSPORINE MODIFIED CAPSULE Y    
cyclosporine, modified GENGRAF CAPSULE Y    
cyclosporine, modified NEORAL CAPSULE Y    
cyclosporine, modified CYCLOSPORINE SOLUTION Y    
cyclosporine, modified CYCLOSPORINE MODIFIED SOLUTION Y    
cyclosporine, modified GENGRAF SOLUTION Y    
cyclosporine, modified NEORAL SOLUTION Y    
everolimus ZORTRESS TABLET Y    
mycophenolate mofetil CELLCEPT CAPSULE Y    
mycophenolate mofetil MYCOPHENOLATE MOFETIL CAPSULE Y    
mycophenolate mofetil CELLCEPT SUSP RECON Y    
mycophenolate mofetil MYCOPHENOLATE MOFETIL SUSP RECON Y    
mycophenolate mofetil CELLCEPT TABLET Y    
mycophenolate mofetil MYCOPHENOLATE MOFETIL TABLET Y    
mycophenolate sodium MYCOPHENOLIC ACID TABLET DR Y    
mycophenolate sodium MYFORTIC TABLET DR Y    
sirolimus RAPAMUNE SOLUTION Y    
sirolimus RAPAMUNE TABLET Y    
sirolimus SIROLIMUS 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