Lysosomal Storage Disorders
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 |
|---|---|---|---|---|---|---|
| taliglucerase alfa | ELELYSO | VIAL | Y | Pharmacy PA | N | |
| agalsidase beta | FABRAZYME | VIAL | N | Pharmacy PA | N | |
| avalglucosidase alfa-ngpt | NEXVIAZYME | VIAL | N | Pharmacy PA | N | |
| cipaglucosidase alfa-atga | POMBILITI | VIAL | N | Pharmacy PA | N | |
| miglustat | MIGLUSTAT | CAPSULE | N | Pharmacy PA | N | |
| miglustat | OPFOLDA | CAPSULE | N | Pharmacy PA | N | |
| elosulfase alfa | VIMIZIM | VIAL | N | |||
| idursulfase | ELAPRASE | VIAL | N | |||
| laronidase | ALDURAZYME | VIAL | N | |||
| vestronidase alfa-vjbk | MEPSEVII | VIAL | N |