Orphan Drug
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 |
|---|---|---|---|---|---|---|
| belumosudil mesylate | REZUROCK | TABLET | N | Medical & Pharmacy PA | Oct 07, 2021 | |
| eculizumab-aagh | EPYSQLI | VIAL | N | Medical & Pharmacy PA | ||
| eculizumab-aeeb | BKEMV | VIAL | N | Medical & Pharmacy PA | ||
| iptacopan HCl | FABHALTA | CAPSULE | N | Medical & Pharmacy PA | ||
| nerandomilast | JASCAYD | TABLET | N | Medical & Pharmacy PA | ||
| zilucoplan sodium | ZILBRYSQ | SYRINGE | N | Medical & Pharmacy PA | ||
| ADAMTS13, recombinant-krhn | ADZYNMA | KIT | Medical & Pharmacy PA | |||
| aficamten | MYQORZO | TABLET | Medical & Pharmacy PA | |||
| alpelisib | VIJOICE | GRAN PACK | Medical & Pharmacy PA | |||
| alpelisib | VIJOICE | TABLET | Medical & Pharmacy PA | |||
| asfotase alfa | STRENSIQ | VIAL | Medical & Pharmacy PA | BILL FFS | ||
| atidarsagene autotemcel | LENMELDY | PLAST. BAG | Medical & Pharmacy PA | BILL FFS | ||
| avacopan | TAVNEOS | CAPSULE | Medical & Pharmacy PA | |||
| axatilimab-csfr | NIKTIMVO | VIAL | Medical & Pharmacy PA | |||
| burosumab-twza | CRYSVITA | VIAL | Medical & Pharmacy PA | Jun 04, 2020 Feb 04, 2021 |
||
| cerliponase alfa | BRINEURA | KIT | Medical & Pharmacy PA | Jun 04, 2020 Feb 04, 2021 |
||
| cerliponase alfa | BRINEURA | VIAL | Medical & Pharmacy PA | Jun 04, 2020 Feb 04, 2021 |
||
| chenodiol | CTEXLI | TABLET | Medical & Pharmacy PA | BILL FFS | ||
| crinecerfont | CRENESSITY | CAPSULE | Medical & Pharmacy PA | |||
| crinecerfont | CRENESSITY | SOLUTION | Medical & Pharmacy PA | |||
| crovalimab-akkz | PIASKY | VIAL | Medical & Pharmacy PA | |||
| danicopan | VOYDEYA | TABLET | Medical & Pharmacy PA | |||
| doxecitine/doxribtimine | KYGEVVI | POWD PACK | Medical & Pharmacy PA | BILL FFS | ||
| eculizumab | SOLIRIS | VIAL | Medical & Pharmacy PA | |||
| eladocagene exuparvovec-tneq | KEBILIDI | VIAL | Medical & Pharmacy PA | BILL FFS | ||
| elafibranor | IQIRVO | TABLET | Medical & Pharmacy PA | |||
| elapegademase-lvlr | REVCOVI | VIAL | Medical & Pharmacy PA | BILL FFS | Feb 04, 2021 | |
| elivaldogene autotemcel | SKYSONA | PLAST. BAG | Medical & Pharmacy PA | BILL FFS | ||
| elosulfase alfa | VIMIZIM | VIAL | Medical & Pharmacy PA | BILL FFS | ||
| fosdenopterin hydrobromide | NULIBRY | VIAL | Medical & Pharmacy PA | Jun 03, 2021 | ||
| galsulfase | NAGLAZYME | VIAL | Medical & Pharmacy PA | BILL FFS | ||
| givosiran sodium | GIVLAARI | VIAL | Medical & Pharmacy PA | Feb 04, 2021 | ||
| idursulfase | ELAPRASE | VIAL | Medical & Pharmacy PA | BILL FFS | ||
| inebilizumab-cdon | UPLIZNA | VIAL | Medical & Pharmacy PA | |||
| leniolisib phosphate | JOENJA | TABLET | Medical & Pharmacy PA | BILL FFS | ||
| levoketoconazole | RECORLEV | TABLET | Medical & Pharmacy PA | |||
| linerixibat | LYNAVOY | TABLET | Medical & Pharmacy PA | |||
| lonafarnib | ZOKINVY | CAPSULE | Medical & Pharmacy PA | BILL FFS | Feb 04, 2021 | |
| lumasiran sodium | OXLUMO | VIAL | Medical & Pharmacy PA | BILL FFS | Feb 04, 2021 | |
| lunsotogene parvec-cwha | OTARMENI | VIAL | Medical & Pharmacy PA | |||
| luspatercept-aamt | REBLOZYL | VIAL | Medical & Pharmacy PA | Jun 04, 2020 Feb 04, 2021 |
||
| maralixibat chloride | LIVMARLI | SOLUTION | Medical & Pharmacy PA | BILL FFS | ||
| maralixibat chloride | LIVMARLI | TABLET | Medical & Pharmacy PA | BILL FFS | ||
| mavacamten | CAMZYOS | CAPSULE | Medical & Pharmacy PA | |||
| mavorixafor | XOLREMDI | CAPSULE | Medical & Pharmacy PA | |||
| mirdametinib | GOMEKLI | CAPSULE | Medical & Pharmacy PA | |||
| mirdametinib | GOMEKLI | TAB SUSP | Medical & Pharmacy PA | |||
| mitapivat sulfate | PYRUKYND | TAB DS PK | Medical & Pharmacy PA | |||
| mitapivat sulfate | AQVESME | TABLET | Medical & Pharmacy PA | |||
| mitapivat sulfate | PYRUKYND | TABLET | Medical & Pharmacy PA | |||
| narsoplimab-wuug | YARTEMLEA | VIAL | Medical & Pharmacy PA | |||
| nedosiran sodium | RIVFLOZA | SYRINGE | Medical & Pharmacy PA | |||
| nedosiran sodium | RIVFLOZA | VIAL | Medical & Pharmacy PA | |||
| nipocalimab-aahu | IMAAVY | VIAL | Medical & Pharmacy PA | |||
| odevixibat | BYLVAY | CAPSULE | Medical & Pharmacy PA | BILL FFS | ||
| odevixibat | BYLVAY | PEL DSP CP | Medical & Pharmacy PA | BILL FFS | ||
| olipudase alfa-rpcp | XENPOZYME | VIAL | Medical & Pharmacy PA | BILL FFS | ||
| palopegteriparatide | YORVIPATH | PEN INJCTR | Medical & Pharmacy PA | |||
| paltusotine HCl | PALSONIFY | TABLET | Medical & Pharmacy PA | |||
| pegcetacoplan | EMPAVELI | VIAL | Medical & Pharmacy PA | |||
| plasminogen, human-tvmh | RYPLAZIM | VIAL | Medical & Pharmacy PA | |||
| pozelimab-bbfg | VEOPOZ | VIAL | Medical & Pharmacy PA | BILL FFS | ||
| ravulizumab-cwvz | ULTOMIRIS | VIAL | Medical & Pharmacy PA | |||
| remestemcel-L-rknd | RYONCIL | KIT | Medical & Pharmacy PA | |||
| remestemcel-L-rknd | RYONCIL | VIAL | Medical & Pharmacy PA | |||
| rezafungin acetate | REZZAYO | VIAL | Medical & Pharmacy PA | |||
| rozanolixizumab-noli | RYSTIGGO | VIAL | Medical & Pharmacy PA | |||
| satralizumab-mwge | ENSPRYNG | SYRINGE | Medical & Pharmacy PA | |||
| seladelpar lysine | LIVDELZI | CAPSULE | Medical & Pharmacy PA | |||
| sodium thiosulfate | PEDMARK | VIAL | Medical & Pharmacy PA | |||
| sutimlimab-jome | ENJAYMO | VIAL | Medical & Pharmacy PA | |||
| thymus tissue-agdc | RETHYMIC | IMPLANT | Medical & Pharmacy PA | BILL FFS | ||
| tividenofusp alfa-eknm | AVLAYAH | VIAL | Medical & Pharmacy PA | BILL FFS | ||
| tofersen | QALSODY | VIAL | Medical & Pharmacy PA | |||
| trientine tetrahydrochloride | CUVRIOR | TABLET | Medical & Pharmacy PA | |||
| velmanase alfa-tycv | LAMZEDE | VIAL | Medical & Pharmacy PA | BILL FFS | ||
| vestronidase alfa-vjbk | MEPSEVII | VIAL | Medical & Pharmacy PA | BILL FFS |