Biologics for Autoimmune Conditions

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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
ADALIMUMAB HUMIRA PEN CROHN-UC-HS STARTER PEN IJ KIT Y PA Document  
ADALIMUMAB HUMIRA PEN PEN IJ KIT Y PA Document  
ADALIMUMAB HUMIRA PEN PSORIASIS-UVEITIS PEN IJ KIT Y PA Document  
ADALIMUMAB HUMIRA SYRINGEKIT Y PA Document  
ADALIMUMAB HUMIRA PEDIATRIC CROHN'S SYRINGEKIT Y PA Document  
ETANERCEPT ENBREL PEN INJCTR Y PA Document  
ETANERCEPT ENBREL SYRINGE Y PA Document  
ETANERCEPT ENBREL VIAL Y PA Document  
ABATACEPT ORENCIA CLICKJECT AUTO INJCT N PA Document  
ABATACEPT ORENCIA SYRINGE N PA Document  
ABATACEPT/MALTOSE ORENCIA VIAL N PA Document  
ANAKINRA KINERET SYRINGE N PA Document  
APREMILAST OTEZLA TAB DS PK N PA Document  
APREMILAST OTEZLA TABLET N PA Document  
CANAKINUMAB/PF ILARIS VIAL N PA Document  
CERTOLIZUMAB PEGOL CIMZIA KIT N PA Document  
CERTOLIZUMAB PEGOL CIMZIA SYRINGEKIT N PA Document  
GOLIMUMAB SIMPONI PEN INJCTR N PA Document  
GOLIMUMAB SIMPONI SYRINGE N PA Document  
GOLIMUMAB SIMPONI ARIA VIAL N PA Document  
INFLIXIMAB REMICADE VIAL 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
NATALIZUMAB TYSABRI VIAL N PA Document  
RITUXIMAB RITUXAN VIAL N PA Document  
SARILUMAB KEVZARA SYRINGE N PA Document  
SECUKINUMAB COSENTYX PEN (2 PENS) PEN INJCTR N PA Document Jul 30, 2015
SECUKINUMAB COSENTYX PEN PEN INJCTR N PA Document Jul 30, 2015
SECUKINUMAB COSENTYX SYRINGE SYRINGE N PA Document Jul 30, 2015
SECUKINUMAB COSENTYX (2 SYRINGES) SYRINGE N PA Document Jul 30, 2015
TOCILIZUMAB ACTEMRA SYRINGE N PA Document  
TOCILIZUMAB ACTEMRA VIAL N PA Document  
TOFACITINIB CITRATE XELJANZ XR TAB ER 24H N PA Document  
TOFACITINIB CITRATE XELJANZ TABLET N PA Document  
USTEKINUMAB STELARA SYRINGE N PA Document  
USTEKINUMAB STELARA VIAL N PA Document  
VEDOLIZUMAB ENTYVIO VIAL N PA Document  
BELIMUMAB BENLYSTA VIAL PA Document