Targeted Immune Modulators

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PDL Reference Documents

Drug Use Review Documents

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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.

Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria New Drug Evaluation
adalimumab HUMIRA(CF) PEN PSOR-UV-ADOL HS PEN IJ KIT Y PA Document  
adalimumab HUMIRA(CF) PEN PEDIATRIC UC PEN IJ KIT Y PA Document  
adalimumab HUMIRA(CF) PEN CROHN'S-UC-HS PEN IJ KIT Y PA Document  
adalimumab HUMIRA(CF) PEN PEN IJ KIT Y PA Document  
adalimumab HUMIRA PEN PSOR-UVEITS-ADOL HS PEN IJ KIT Y PA Document  
adalimumab HUMIRA PEN CROHN'S-UC-HS PEN IJ KIT Y PA Document  
adalimumab HUMIRA PEN PEN IJ KIT Y PA Document  
adalimumab HUMIRA(CF) PEDIATRIC CROHN'S SYRINGEKIT Y PA Document  
adalimumab HUMIRA(CF) SYRINGEKIT Y PA Document  
adalimumab HUMIRA SYRINGEKIT Y PA Document  
etanercept ENBREL MINI CARTRIDGE Y PA Document  
etanercept ENBREL SURECLICK PEN INJCTR Y PA Document  
etanercept ENBREL SYRINGE Y PA Document  
etanercept ENBREL VIAL Y PA Document  
secukinumab COSENTYX UNOREADY PEN PEN INJCTR Y PA Document Jul 30, 2015
secukinumab COSENTYX SENSOREADY PEN PEN INJCTR Y PA Document Jul 30, 2015
secukinumab COSENTYX SENSOREADY (2 PENS) PEN INJCTR Y PA Document Jul 30, 2015
secukinumab COSENTYX SYRINGE SYRINGE Y PA Document Jul 30, 2015
secukinumab COSENTYX (2 SYRINGES) SYRINGE Y PA Document Jul 30, 2015
abatacept ORENCIA CLICKJECT AUTO INJCT N PA Document  
abatacept ORENCIA SYRINGE N PA Document  
abatacept/maltose ORENCIA VIAL N PA Document  
adalimumab-aacf ADALIMUMAB-AACF(CF) PEN PEN IJ KIT N PA Document  
adalimumab-aacf IDACIO(CF) PEN PSORIASIS PEN IJ KIT N PA Document  
adalimumab-aacf IDACIO(CF) PEN CROHN'S-UC PEN IJ KIT N PA Document  
adalimumab-aacf IDACIO(CF) PEN PEN IJ KIT N PA Document  
adalimumab-aacf IDACIO(CF) SYRINGEKIT N PA Document  
adalimumab-aaty YUFLYMA(CF) AUTOINJECTOR AUTOINJKIT N PA Document  
adalimumab-aaty YUFLYMA(CF) AI CROHN'S-UC-HS AUTOINJKIT N PA Document  
adalimumab-aaty YUFLYMA(CF) SYRINGEKIT N PA Document  
adalimumab-adaz HYRIMOZ(CF) PEN PSORIASIS PEN INJCTR N PA Document  
adalimumab-adaz HYRIMOZ(CF) PEN PEN INJCTR N PA Document  
adalimumab-adaz ADALIMUMAB-ADAZ(CF) PEN PEN INJCTR N PA Document  
adalimumab-adaz HYRIMOZ(CF) PEN CROHN-UC START PEN INJCTR N PA Document  
adalimumab-adaz HYRIMOZ(CF) SYRINGE N PA Document  
adalimumab-adaz ADALIMUMAB-ADAZ(CF) SYRINGE N PA Document  
adalimumab-adaz HYRIMOZ(CF) PEDIATRIC CROHN'S SYRINGE N PA Document  
adalimumab-adbm ADALIMUMAB-ADBM(CF) PEN CROHNS PEN IJ KIT N PA Document  
adalimumab-adbm CYLTEZO(CF) PEN CROHN'S-UC-HS PEN IJ KIT N PA Document  
adalimumab-adbm ADALIMUMAB-ADBM(CF) PEN PS-UV PEN IJ KIT N PA Document  
adalimumab-adbm ADALIMUMAB-ADBM(CF)PEN PEN IJ KIT N PA Document  
adalimumab-adbm CYLTEZO(CF) PEN PEN IJ KIT N PA Document  
adalimumab-adbm CYLTEZO(CF) PEN PSORIASIS-UV PEN IJ KIT N PA Document  
adalimumab-adbm ADALIMUMAB-ADBM(CF) SYRINGEKIT N PA Document  
adalimumab-adbm CYLTEZO(CF) SYRINGEKIT N PA Document  
adalimumab-afzb ABRILADA(CF) PEN PEN IJ KIT N PA Document  
adalimumab-afzb ABRILADA(CF) SYRINGEKIT N PA Document  
adalimumab-aqvh YUSIMRY(CF) PEN PEN INJCTR N PA Document  
adalimumab-atto AMJEVITA(CF) AUTOINJECTOR AUTO INJCT N PA Document  
adalimumab-atto AMJEVITA(CF) SYRINGE N PA Document  
adalimumab-bwwd HADLIMA(CF) PUSHTOUCH AUTO INJCT N PA Document  
adalimumab-bwwd HADLIMA PUSHTOUCH AUTO INJCT N PA Document  
adalimumab-bwwd HADLIMA(CF) SYRINGE N PA Document  
adalimumab-bwwd HADLIMA SYRINGE N PA Document  
adalimumab-fkjp HULIO(CF) PEN PEN IJ KIT N PA Document  
adalimumab-fkjp ADALIMUMAB-FKJP(CF) PEN PEN IJ KIT N PA Document  
adalimumab-fkjp HULIO(CF) SYRINGEKIT N PA Document  
adalimumab-fkjp ADALIMUMAB-FKJP(CF) SYRINGEKIT N PA Document  
anakinra KINERET SYRINGE N PA Document  
apremilast OTEZLA TAB DS PK N PA Document  
apremilast OTEZLA TABLET N PA Document  
baricitinib OLUMIANT TABLET N PA Document  
bimekizumab-bkzx BIMZELX AUTOINJECTOR AUTO INJCT N PA Document  
bimekizumab-bkzx BIMZELX SYRINGE N PA Document  
brodalumab SILIQ SYRINGE N PA Document  
canakinumab/PF ILARIS VIAL N PA Document  
certolizumab pegol CIMZIA KIT N PA Document  
certolizumab pegol CIMZIA SYRINGEKIT N PA Document  
deucravacitinib SOTYKTU TABLET N PA Document  
etrasimod arginine VELSIPITY TABLET N PA Document  
golimumab SIMPONI PEN INJCTR N PA Document  
golimumab SIMPONI SYRINGE N PA Document  
golimumab SIMPONI ARIA VIAL N PA Document  
guselkumab TREMFYA AUTO INJCT N PA Document  
guselkumab TREMFYA SYRINGE N PA Document  
infliximab INFLIXIMAB VIAL N PA Document  
infliximab REMICADE VIAL N PA Document  
infliximab-abda RENFLEXIS VIAL N PA Document  
infliximab-axxq AVSOLA VIAL N PA Document  
infliximab-dyyb ZYMFENTRA PEN IJ KIT N PA Document  
infliximab-dyyb ZYMFENTRA SYRINGEKIT N PA Document  
infliximab-dyyb INFLECTRA VIAL N PA Document  
ixekizumab TALTZ AUTOINJECTOR (3 PACK) AUTO INJCT N PA Document Nov 17, 2016
ixekizumab TALTZ AUTOINJECTOR (2 PACK) AUTO INJCT N PA Document Nov 17, 2016
ixekizumab TALTZ AUTOINJECTOR AUTO INJCT N PA Document Nov 17, 2016
ixekizumab TALTZ SYRINGE SYRINGE N PA Document Nov 17, 2016
mirikizumab-mrkz OMVOH PEN PEN INJCTR N PA Document  
mirikizumab-mrkz OMVOH VIAL N PA Document  
natalizumab TYSABRI VIAL N PA Document  
risankizumab-rzaa SKYRIZI PEN PEN INJCTR N PA Document  
risankizumab-rzaa SKYRIZI SYRINGE N PA Document  
risankizumab-rzaa SKYRIZI VIAL N PA Document  
risankizumab-rzaa SKYRIZI ON-BODY WEAR INJCT N PA Document  
rituximab RITUXAN VIAL N PA Document  
rituximab-abbs TRUXIMA VIAL N PA Document  
rituximab-arrx RIABNI VIAL N PA Document  
rituximab-pvvr RUXIENCE VIAL N PA Document  
sarilumab KEVZARA PEN INJCTR N PA Document  
sarilumab KEVZARA SYRINGE N PA Document  
secukinumab COSENTYX VIAL N PA Document Jul 30, 2015
spesolimab-sbzo SPEVIGO VIAL N PA Document  
tildrakizumab-asmn ILUMYA SYRINGE N PA Document  
tocilizumab ACTEMRA ACTPEN PEN INJCTR N PA Document  
tocilizumab ACTEMRA SYRINGE N PA Document  
tocilizumab ACTEMRA VIAL N PA Document  
tofacitinib citrate XELJANZ SOLUTION N PA Document  
tofacitinib citrate XELJANZ XR TAB ER 24H N PA Document  
tofacitinib citrate XELJANZ TABLET N PA Document  
upadacitinib RINVOQ TAB ER 24H N PA Document  
ustekinumab STELARA SYRINGE N PA Document  
ustekinumab STELARA VIAL N PA Document  
vedolizumab ENTYVIO PEN PEN INJCTR N PA Document  
vedolizumab ENTYVIO VIAL N PA Document  
adalimumab-ryvk SIMLANDI(CF) AUTOINJECTOR AUTOINJKIT PA Document  
ritlecitinib tosylate LITFULO CAPSULE PA Document  
spesolimab-sbzo SPEVIGO SYRINGE PA Document  
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