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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.
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 |
|---|---|---|---|---|---|---|
| abrocitinib | CIBINQO | TABLET | N | Medical & Pharmacy PA | ||
| benralizumab | FASENRA PEN | AUTO INJCT | N | Medical & Pharmacy PA | ||
| benralizumab | FASENRA | SYRINGE | N | Medical & Pharmacy PA | ||
| depemokimab-ulaa | EXDENSUR | SYRINGE | N | Medical & Pharmacy PA | ||
| dupilumab | DUPIXENT PEN | PEN INJCTR | N | Medical & Pharmacy PA | ||
| dupilumab | DUPIXENT SYRINGE | SYRINGE | N | Medical & Pharmacy PA | ||
| lebrikizumab-lbkz | EBGLYSS PEN | PEN INJCTR | N | Medical & Pharmacy PA | Oct 02, 2025 | |
| lebrikizumab-lbkz | EBGLYSS SYRINGE | SYRINGE | N | Medical & Pharmacy PA | Oct 02, 2025 | |
| mepolizumab | NUCALA | AUTO INJCT | N | Medical & Pharmacy PA | ||
| mepolizumab | NUCALA | SYRINGE | N | Medical & Pharmacy PA | ||
| mepolizumab | NUCALA | VIAL | N | Medical & Pharmacy PA | ||
| nemolizumab-ilto | NEMLUVIO | PEN INJCTR | N | Medical & Pharmacy PA | ||
| omalizumab | XOLAIR | AUTO INJCT | N | Medical & Pharmacy PA | ||
| omalizumab | XOLAIR | SYRINGE | N | Medical & Pharmacy PA | ||
| omalizumab | XOLAIR | VIAL | N | Medical & Pharmacy PA | ||
| omalizumab-igec | OMLYCLO | SYRINGE | N | Medical & Pharmacy PA | ||
| remibrutinib | RHAPSIDO | TABLET | N | Medical & Pharmacy PA | ||
| reslizumab | CINQAIR | VIAL | N | Medical & Pharmacy PA | ||
| tezepelumab-ekko | TEZSPIRE | PEN INJCTR | N | Medical & Pharmacy PA | ||
| tezepelumab-ekko | TEZSPIRE | SYRINGE | N | Medical & Pharmacy PA | ||
| tralokinumab-ldrm | ADBRY AUTOINJECTOR | AUTO INJCT | N | Medical & Pharmacy PA | ||
| tralokinumab-ldrm | ADBRY | SYRINGE | N | Medical & Pharmacy PA |