Immunosuppressants
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| azathioprine | AZATHIOPRINE | TABLET | Y | N | ||
| azathioprine | IMURAN | TABLET | Y | N | ||
| cyclosporine | CYCLOSPORINE | CAPSULE | Y | N | ||
| cyclosporine, modified | NEORAL | CAPSULE | Y | N | ||
| cyclosporine, modified | CYCLOSPORINE MODIFIED | CAPSULE | Y | N | ||
| cyclosporine, modified | GENGRAF | CAPSULE | Y | N | ||
| cyclosporine, modified | CYCLOSPORINE MODIFIED | SOLUTION | Y | N | ||
| everolimus | EVEROLIMUS | TABLET | Y | N | ||
| mycophenolate mofetil | CELLCEPT | CAPSULE | Y | N | ||
| mycophenolate mofetil | CELLCEPT | TABLET | Y | N | ||
| mycophenolate sodium | MYFORTIC | TABLET DR | Y | N | ||
| sirolimus | SIROLIMUS | SOLUTION | Y | N | ||
| tacrolimus | ASTAGRAF XL | CAP ER 24H | Y | N | ||
| tacrolimus | TACROLIMUS | CAPSULE | Y | N | ||
| tacrolimus | PROGRAF | CAPSULE | Y | N | ||
| voclosporin | LUPKYNIS | CAPSULE | N | Pharmacy PA | N |