Lysosomal Storage Disorders
PDL Reference Documents
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 |
|---|---|---|---|---|---|
| taliglucerase alfa | ELELYSO | VIAL | Y | PA Document | |
| agalsidase beta | FABRAZYME | VIAL | N | PA Document | |
| alglucosidase alfa | LUMIZYME | VIAL | N | PA Document | Apr 01, 2021 |
| avalglucosidase alfa-ngpt | NEXVIAZYME | VIAL | N | PA Document | |
| cipaglucosidase alfa-atga | POMBILITI | VIAL | N | PA Document | |
| eliglustat tartrate | CERDELGA | CAPSULE | N | PA Document | |
| imiglucerase | CEREZYME | VIAL | N | PA Document | |
| migalastat HCl | GALAFOLD | CAPSULE | N | PA Document | |
| miglustat | YARGESA | CAPSULE | N | PA Document | |
| miglustat | ZAVESCA | CAPSULE | N | PA Document | |
| miglustat | OPFOLDA | CAPSULE | N | PA Document | |
| miglustat | MIGLUSTAT | CAPSULE | N | PA Document | |
| pegunigalsidase alfa-iwxj | ELFABRIO | VIAL | N | PA Document | |
| velaglucerase alfa | VPRIV | VIAL | N | PA Document | |
| elosulfase alfa | VIMIZIM | VIAL | |||
| galsulfase | NAGLAZYME | VIAL | |||
| idursulfase | ELAPRASE | VIAL | |||
| laronidase | ALDURAZYME | VIAL | |||
| sebelipase alfa | KANUMA | VIAL | |||
| vestronidase alfa-vjbk | MEPSEVII | VIAL |