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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 |
|---|---|---|---|---|---|---|
| COVID-19 vac, tris(Pfizer)/PF | COMIRNATY | VIAL | N | |||
| cytomegalovirus immune globuln | CYTOGAM | VIAL | N | |||
| hepatitis B immune globulin | HYPERHEP B | SYRINGE | N | |||
| hepatitis B immune globulin | NABI-HB | VIAL | N | |||
| histoplasmin | HISTOPLASMIN | VIAL | N | |||
| rabies immune globulin/PF | KEDRAB | VIAL | N | |||
| Rho(D) immune globulin | RHOGAM ULTRA-FILTERED PLUS | SYRINGE | N | |||
| Rho(D) immune globulin/maltose | WINRHO SDF | VIAL | N | |||
| tuberculin,purif.prot.deriv. | APLISOL | VIAL | N |