Misc Antivirals

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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
ACYCLOVIR SODIUM ACYCLOVIR SODIUM VIAL    
CIDOFOVIR CIDOFOVIR VIAL    
GANCICLOVIR SODIUM GANCICLOVIR SODIUM VIAL    
GANCICLOVIR SODIUM CYTOVENE VIAL    
PALIVIZUMAB SYNAGIS VIAL PA Document  
RIBAVIRIN VIRAZOLE VIAL-NEB    
RIBAVIRIN RIBAVIRIN VIAL-NEB    
SINECATECHINS VEREGEN OINT. (G)    
VALGANCICLOVIR HCL VALGANCICLOVIR HCL SOLN RECON    
VALGANCICLOVIR HCL VALCYTE SOLN RECON    
VALGANCICLOVIR HCL VALCYTE TABLET    
VALGANCICLOVIR HCL VALGANCICLOVIR HCL TABLET