Multiple Sclerosis
PDL Reference Documents
Drug Use Review 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 |
|---|---|---|---|---|---|---|
| interferon beta-1a | AVONEX | SYRINGE | Y | N | ||
| interferon beta-1a | AVONEX (4 PACK) | SYRINGEKIT | Y | N | ||
| interferon beta-1a/albumin | REBIF | SYRINGE | Y | N | ||
| interferon beta-1b | BETASERON | KIT | Y | N | ||
| peginterferon beta-1a | PLEGRIDY | SYRINGE | Y | N | ||
| alemtuzumab | LEMTRADA | VIAL | N | Pharmacy PA | N | |
| dalfampridine | AMPYRA | TAB ER 12H | N | Pharmacy PA | N | Mar 29, 2012 Jul 25, 2013 May 26, 2016 |
| dimethyl fumarate | DIMETHYL FUMARATE | CAPSULE DR | N | Pharmacy PA | N | |
| diroximel fumarate | VUMERITY | CAPSULE DR | N | Pharmacy PA | N | |
| fingolimod HCl | FINGOLIMOD | CAPSULE | N | Pharmacy PA | N | |
| glatiramer acetate | GLATIRAMER ACETATE | SYRINGE | N | Pharmacy PA | N | |
| glatiramer acetate | COPAXONE | SYRINGE | N | Pharmacy PA | N | |
| monomethyl fumarate | BAFIERTAM | CAPSULE DR | N | Pharmacy PA | N | |
| ocrelizumab-hyaluronidase-ocsq | OCREVUS ZUNOVO | VIAL | N | Pharmacy PA | N | |
| ozanimod hydrochloride | ZEPOSIA | CAP DS PK | N | Pharmacy PA | N | |
| ponesimod | PONVORY | TAB DS PK | N | Pharmacy PA | N | |
| siponimod | MAYZENT | TAB DS PK | N | Pharmacy PA | N | |
| siponimod | MAYZENT | TABLET | N | Pharmacy PA | N |