Hereditary Angioedema
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 |
|---|---|---|---|---|---|---|
| C1 esterase inhibitor | BERINERT | KIT | Y | Medical & Pharmacy PA | ||
| C1 esterase inhibitor | BERINERT | VIAL | Y | Medical & Pharmacy PA | ||
| C1 esterase inhibitor | HAEGARDA | VIAL | Y | Medical & Pharmacy PA | ||
| icatibant acetate | ICATIBANT | SYRINGE | Y | Medical & Pharmacy PA | ||
| berotralstat hydrochloride | ORLADEYO | CAPSULE | N | Medical & Pharmacy PA | ||
| berotralstat hydrochloride | ORLADEYO | PELET PACK | N | Medical & Pharmacy PA | ||
| C1 esterase inhibitor | CINRYZE | VIAL | N | Medical & Pharmacy PA | ||
| C1 esterase inhibitor, recomb | RUCONEST | VIAL | N | Medical & Pharmacy PA | ||
| donidalorsen sodium | DAWNZERA | AUTO INJCT | N | Medical & Pharmacy PA | ||
| ecallantide | KALBITOR | VIAL | N | Medical & Pharmacy PA | ||
| garadacimab-gxii | ANDEMBRY AUTOINJECTOR | AUTO INJCT | N | Medical & Pharmacy PA | ||
| icatibant acetate | SAJAZIR | SYRINGE | N | Medical & Pharmacy PA | ||
| icatibant acetate | FIRAZYR | SYRINGE | N | Medical & Pharmacy PA | ||
| lanadelumab-flyo | TAKHZYRO | SYRINGE | N | Medical & Pharmacy PA | ||
| sebetralstat | EKTERLY | TABLET | N | Medical & Pharmacy PA |