Cystic Fibrosis
PDL Reference Documents
- Inhaled Drugs for Cystic Fibrosis - Dec 02, 2021
- Cystic Fibrosis - Jun 03, 2021
- Cystic Fibrosis Class Update - Jun 04, 2020
- Cystic Fibrosis - Sep 26, 2019
- Oral Cystic Fibrosis Modulators - Sep 27, 2018
- Oral Cystic Fibrosis Modulators - Jul 26, 2018
- Oral Cystic Fibrosis Modulators - Nov 17, 2016
- Inhaled Drugs for Cystic Fibrosis - Jan 28, 2016
- Inhaled Medications for Cystic Fibrosis - May 28, 2015
- Cystic Fibrosis Abbreviated Class Update - May 29, 2014
- Cystic Fibrosis - Inhaled Antibiotics Class Update - Mar 27, 2014
- Abbreviated Class Review: Fat-Soluble Vitamins for the Use of Cystic Fybrosis - May 30, 2013
- Abbreviated Drug Evaluation: Hypertonic Saline Inhalation for Cystic Fybrosis - Sep 27, 2012
- Abbreviated Class Review: Inhaled Antibiotics and Dornase Alfa for Cystic Fibrosis - Aug 30, 2012
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 71558059028 | ARIKAYCE | amikacin liposomal/neb.accessr | VIAL-NEB | 590 mg/8.4 mL | N | Y | PA Document |
| 61958090101 | CAYSTON | aztreonam lysine | VIAL-NEB | 75 mg/mL | N | Y | |
| 50242010039 | PULMOZYME | dornase alfa | SOLUTION | 1 mg/mL | Y | Y | |
| 50242010040 | PULMOZYME | dornase alfa | SOLUTION | 1 mg/mL | Y | Y | |
| 51167044601 | TRIKAFTA | elexacaftor/tezacaftor/ivacaft | GRAN PK SQ | 100 mg-50 mg-75 mg (day)/75 mg (night) | N | Y | PA Document |
| 51167044501 | TRIKAFTA | elexacaftor/tezacaftor/ivacaft | GRAN PK SQ | 80 mg-40 mg-60 mg (day)/59.5 mg (night) | N | Y | PA Document |
| 51167033101 | TRIKAFTA | elexacaftor/tezacaftor/ivacaft | TABLET SEQ | 100 mg-50 mg-75 mg (day)/150 mg (night) | N | Y | PA Document |
| 51167010602 | TRIKAFTA | elexacaftor/tezacaftor/ivacaft | TABLET SEQ | 50 mg-25 mg-37.5 mg (day)/75 mg (night) | N | Y | PA Document |
| 51167077001 | KALYDECO | ivacaftor | GRAN PACK | 13.4 mg | N | Y | PA Document |
| 51167060001 | KALYDECO | ivacaftor | GRAN PACK | 25 mg | N | Y | PA Document |
| 51167078501 | KALYDECO | ivacaftor | GRAN PACK | 5.8 mg | N | Y | PA Document |
| 51167030001 | KALYDECO | ivacaftor | GRAN PACK | 50 mg | N | Y | PA Document |
| 51167040001 | KALYDECO | ivacaftor | GRAN PACK | 75 mg | N | Y | PA Document |
| 51167020001 | KALYDECO | ivacaftor | TABLET | 150 mg | N | Y | PA Document |
| 51167090001 | ORKAMBI | lumacaftor/ivacaftor | GRAN PACK | 100 mg-125 mg | N | Y | PA Document |
| 51167050002 | ORKAMBI | lumacaftor/ivacaftor | GRAN PACK | 150 mg-188 mg | N | Y | PA Document |
| 51167012201 | ORKAMBI | lumacaftor/ivacaftor | GRAN PACK | 75 mg-94 mg | N | Y | PA Document |
| 51167070002 | ORKAMBI | lumacaftor/ivacaftor | TABLET | 100 mg-125 mg | N | Y | PA Document |
| 51167080901 | ORKAMBI | lumacaftor/ivacaftor | TABLET | 200 mg-125 mg | N | Y | PA Document |
| 10122021201 | BRONCHITOL | mannitol | CAP W/DEV | 40 mg | N | Y | |
| 10122021204 | BRONCHITOL | mannitol | CAP W/DEV | 40 mg | N | Y | |
| 10122021256 | BRONCHITOL | mannitol | CAP W/DEV | 40 mg | N | Y | |
| 58980019003 | SODIUM CHLORIDE | sodium chloride for inhalation | VIAL-NEB | 0.9 % | Y | N | |
| 58980019005 | SODIUM CHLORIDE | sodium chloride for inhalation | VIAL-NEB | 0.9 % | Y | N | |
| 00054880925 | SODIUM CHLORIDE | sodium chloride for inhalation | VIAL-NEB | 0.9 % | Y | Y | |
| 00054881025 | SODIUM CHLORIDE | sodium chloride for inhalation | VIAL-NEB | 0.9 % | Y | Y | |
| 00378698501 | SODIUM CHLORIDE | sodium chloride for inhalation | VIAL-NEB | 0.9 % | Y | Y | |
| 00378698601 | SODIUM CHLORIDE | sodium chloride for inhalation | VIAL-NEB | 0.9 % | Y | Y | |
| 00378698789 | SODIUM CHLORIDE | sodium chloride for inhalation | VIAL-NEB | 0.9 % | Y | Y | |
| 00378699889 | SODIUM CHLORIDE | sodium chloride for inhalation | VIAL-NEB | 10 % | Y | Y | |
| 51167066101 | SYMDEKO | tezacaftor/ivacaftor | TABLET SEQ | 100 mg-150 mg (day)/150 mg (night) | N | Y | PA Document |
| 51167011301 | SYMDEKO | tezacaftor/ivacaftor | TABLET SEQ | 50 mg-75 mg (day)/75 mg (night) | N | Y | PA Document |
| 10122082004 | BETHKIS | tobramycin | AMPUL-NEB | 300 mg/4 mL | N | Y | |
| 10122082028 | BETHKIS | tobramycin | AMPUL-NEB | 300 mg/4 mL | N | Y | |
| 10122082056 | BETHKIS | tobramycin | AMPUL-NEB | 300 mg/4 mL | N | Y | |
| 00093375004 | TOBRAMYCIN | tobramycin | AMPUL-NEB | 300 mg/4 mL | N | Y | |
| 00093375028 | TOBRAMYCIN | tobramycin | AMPUL-NEB | 300 mg/4 mL | N | Y | |
| 00093375063 | TOBRAMYCIN | tobramycin | AMPUL-NEB | 300 mg/4 mL | N | Y | |
| 66993019544 | TOBRAMYCIN | tobramycin | AMPUL-NEB | 300 mg/4 mL | N | Y | |
| 66993019594 | TOBRAMYCIN | tobramycin | AMPUL-NEB | 300 mg/4 mL | N | Y | |
| 70756061756 | TOBRAMYCIN | tobramycin | AMPUL-NEB | 300 mg/4 mL | N | Y | |
| 72603063004 | TOBRAMYCIN | tobramycin | AMPUL-NEB | 300 mg/4 mL | N | Y | |
| 72603063056 | TOBRAMYCIN | tobramycin | AMPUL-NEB | 300 mg/4 mL | N | Y | |
| 49502040111 | TOBI PODHALER | tobramycin | CAP W/DEV | 28 mg | N | Y | |
| 49502040124 | TOBI PODHALER | tobramycin | CAP W/DEV | 28 mg | N | Y | |
| 49502040156 | TOBI PODHALER | tobramycin | CAP W/DEV | 28 mg | N | Y | |
| 49502034573 | TOBI | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 49502034599 | TOBI | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 00093408563 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 16714011902 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 16714011903 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 42571040809 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 42571040819 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 42571040892 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 43598060504 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 43598060511 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 43598060556 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 43598060558 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 47335017148 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 47335017149 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 60687073179 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 60687073183 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 65162091446 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 67877067869 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 67877067870 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 68180096204 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 68180096256 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 70756060444 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 70756060456 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 72603043004 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 72603043056 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 76204002904 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 76204002956 | TOBRAMYCIN | tobramycin in 0.225% sod chlor | AMPUL-NEB | 300 mg/5 mL | Y | Y | |
| 24492085056 | KITABIS PAK | tobramycin/nebulizer | AMPUL-NEB | 300 mg/5 mL | N | Y | |
| 70644089999 | TOBRAMYCIN | tobramycin/nebulizer | AMPUL-NEB | 300 mg/5 mL | N | Y | |
| 51167012101 | ALYFTREK | vanzacaftor/tezacaf/deutivacaf | TABLET | 10 mg-50 mg-125 mg | N | Y | PA Document |
| 51167013501 | ALYFTREK | vanzacaftor/tezacaf/deutivacaf | TABLET | 4 mg-20 mg-50 mg | N | Y | PA Document |