Iron Replacement, Not Oral

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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
FERRIC CARBOXYMALTOSE INJECTAFER VIAL    
FERUMOXYTOL FERAHEME VIAL    
IRON DEXTRAN COMPLEX INFED VIAL    
IRON SUCROSE COMPLEX VENOFER VIAL    
PLERIXAFOR MOZOBIL VIAL    
SODIUM FERRIC GLUCONAT/SUCROSE SOD FERRIC GLUCONATE COMPLEX VIAL    
SODIUM FERRIC GLUCONAT/SUCROSE FERRLECIT VIAL