Erythropoiesis Stimulating Agents

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
55513009801 ARANESP darbepoetin alfa in polysorbat SYRINGE 10 mcg/0.4 mL Y Y  
55513009804 ARANESP darbepoetin alfa in polysorbat SYRINGE 10 mcg/0.4 mL Y Y  
55513002501 ARANESP darbepoetin alfa in polysorbat SYRINGE 100 mcg/0.5 mL Y Y  
55513002504 ARANESP darbepoetin alfa in polysorbat SYRINGE 100 mcg/0.5 mL Y Y  
55513002701 ARANESP darbepoetin alfa in polysorbat SYRINGE 150 mcg/0.3 mL Y Y  
55513002704 ARANESP darbepoetin alfa in polysorbat SYRINGE 150 mcg/0.3 mL Y Y  
55513002801 ARANESP darbepoetin alfa in polysorbat SYRINGE 200 mcg/0.4 mL Y Y  
55513005701 ARANESP darbepoetin alfa in polysorbat SYRINGE 25 mcg/0.42 mL Y Y  
55513005704 ARANESP darbepoetin alfa in polysorbat SYRINGE 25 mcg/0.42 mL Y Y  
55513011101 ARANESP darbepoetin alfa in polysorbat SYRINGE 300 mcg/0.6 mL Y Y  
55513002101 ARANESP darbepoetin alfa in polysorbat SYRINGE 40 mcg/0.4 mL Y Y  
55513002104 ARANESP darbepoetin alfa in polysorbat SYRINGE 40 mcg/0.4 mL Y Y  
55513003201 ARANESP darbepoetin alfa in polysorbat SYRINGE 500 mcg/mL Y Y  
55513002301 ARANESP darbepoetin alfa in polysorbat SYRINGE 60 mcg/0.3 mL Y Y  
55513002304 ARANESP darbepoetin alfa in polysorbat SYRINGE 60 mcg/0.3 mL Y Y  
55513000501 ARANESP darbepoetin alfa in polysorbat VIAL 100 mcg/mL Y Y  
55513000504 ARANESP darbepoetin alfa in polysorbat VIAL 100 mcg/mL Y Y  
55513000601 ARANESP darbepoetin alfa in polysorbat VIAL 200 mcg/mL Y Y  
55513000201 ARANESP darbepoetin alfa in polysorbat VIAL 25 mcg/mL Y Y  
55513000204 ARANESP darbepoetin alfa in polysorbat VIAL 25 mcg/mL Y Y  
55513000301 ARANESP darbepoetin alfa in polysorbat VIAL 40 mcg/mL Y Y  
55513000304 ARANESP darbepoetin alfa in polysorbat VIAL 40 mcg/mL Y Y  
55513000401 ARANESP darbepoetin alfa in polysorbat VIAL 60 mcg/mL Y Y  
55513000404 ARANESP darbepoetin alfa in polysorbat VIAL 60 mcg/mL Y Y  
55513014401 EPOGEN epoetin alfa VIAL 10,000 unit/mL N Y  
55513014410 EPOGEN epoetin alfa VIAL 10,000 unit/mL N Y  
59676031000 PROCRIT epoetin alfa VIAL 10,000 unit/mL N Y  
59676031001 PROCRIT epoetin alfa VIAL 10,000 unit/mL N Y  
59676031002 PROCRIT epoetin alfa VIAL 10,000 unit/mL N Y  
55513012601 EPOGEN epoetin alfa VIAL 2,000 unit/mL N Y  
55513012610 EPOGEN epoetin alfa VIAL 2,000 unit/mL N Y  
59676030200 PROCRIT epoetin alfa VIAL 2,000 unit/mL N Y  
59676030201 PROCRIT epoetin alfa VIAL 2,000 unit/mL N Y  
55513028301 EPOGEN epoetin alfa VIAL 20,000 unit/2 mL N Y  
55513028310 EPOGEN epoetin alfa VIAL 20,000 unit/2 mL N Y  
59676031200 PROCRIT epoetin alfa VIAL 20,000 unit/2 mL N Y  
59676031204 PROCRIT epoetin alfa VIAL 20,000 unit/2 mL N Y  
55513047801 EPOGEN epoetin alfa VIAL 20,000 unit/mL N Y  
55513047810 EPOGEN epoetin alfa VIAL 20,000 unit/mL N Y  
59676032000 PROCRIT epoetin alfa VIAL 20,000 unit/mL N Y  
59676032004 PROCRIT epoetin alfa VIAL 20,000 unit/mL N Y  
55513026701 EPOGEN epoetin alfa VIAL 3,000 unit/mL N Y  
55513026710 EPOGEN epoetin alfa VIAL 3,000 unit/mL N Y  
59676030300 PROCRIT epoetin alfa VIAL 3,000 unit/mL N Y  
59676030301 PROCRIT epoetin alfa VIAL 3,000 unit/mL N Y  
55513014801 EPOGEN epoetin alfa VIAL 4,000 unit/mL N Y  
55513014810 EPOGEN epoetin alfa VIAL 4,000 unit/mL N Y  
59676030400 PROCRIT epoetin alfa VIAL 4,000 unit/mL N Y  
59676030401 PROCRIT epoetin alfa VIAL 4,000 unit/mL N Y  
59676034000 PROCRIT epoetin alfa VIAL 40,000 unit/mL N Y  
59676034001 PROCRIT epoetin alfa VIAL 40,000 unit/mL N Y  
00069130801 RETACRIT epoetin alfa-epbx VIAL 10,000 unit/mL N Y  
00069130810 RETACRIT epoetin alfa-epbx VIAL 10,000 unit/mL N Y  
59353001001 RETACRIT epoetin alfa-epbx VIAL 10,000 unit/mL N Y  
59353001010 RETACRIT epoetin alfa-epbx VIAL 10,000 unit/mL N Y  
00069130501 RETACRIT epoetin alfa-epbx VIAL 2,000 unit/mL N Y  
00069130510 RETACRIT epoetin alfa-epbx VIAL 2,000 unit/mL N Y  
59353000201 RETACRIT epoetin alfa-epbx VIAL 2,000 unit/mL N Y  
59353000210 RETACRIT epoetin alfa-epbx VIAL 2,000 unit/mL N Y  
00069131801 RETACRIT epoetin alfa-epbx VIAL 20,000 unit/2 mL N Y  
00069131810 RETACRIT epoetin alfa-epbx VIAL 20,000 unit/2 mL N Y  
59353022001 RETACRIT epoetin alfa-epbx VIAL 20,000 unit/2 mL N Y  
59353022010 RETACRIT epoetin alfa-epbx VIAL 20,000 unit/2 mL N Y  
00069131101 RETACRIT epoetin alfa-epbx VIAL 20,000 unit/mL N Y  
00069131110 RETACRIT epoetin alfa-epbx VIAL 20,000 unit/mL N Y  
59353012001 RETACRIT epoetin alfa-epbx VIAL 20,000 unit/mL N Y  
59353012010 RETACRIT epoetin alfa-epbx VIAL 20,000 unit/mL N Y  
00069130601 RETACRIT epoetin alfa-epbx VIAL 3,000 unit/mL N Y  
00069130610 RETACRIT epoetin alfa-epbx VIAL 3,000 unit/mL N Y  
59353000301 RETACRIT epoetin alfa-epbx VIAL 3,000 unit/mL N Y  
59353000310 RETACRIT epoetin alfa-epbx VIAL 3,000 unit/mL N Y  
00069130701 RETACRIT epoetin alfa-epbx VIAL 4,000 unit/mL N Y  
00069130710 RETACRIT epoetin alfa-epbx VIAL 4,000 unit/mL N Y  
59353000401 RETACRIT epoetin alfa-epbx VIAL 4,000 unit/mL N Y  
59353000410 RETACRIT epoetin alfa-epbx VIAL 4,000 unit/mL N Y  
00069130901 RETACRIT epoetin alfa-epbx VIAL 40,000 unit/mL N Y  
00069130904 RETACRIT epoetin alfa-epbx VIAL 40,000 unit/mL N Y  
59353040309 MIRCERA methoxy peg-epoetin beta SYRINGE 100 mcg/0.3 mL N Y  
59353040709 MIRCERA methoxy peg-epoetin beta SYRINGE 120 mcg/0.3 mL N Y  
59353040409 MIRCERA methoxy peg-epoetin beta SYRINGE 150 mcg/0.3 mL N Y  
00004040509 MIRCERA methoxy peg-epoetin beta SYRINGE 200 mcg/0.3 mL N Y  
59353040509 MIRCERA methoxy peg-epoetin beta SYRINGE 200 mcg/0.3 mL N Y  
59353040009 MIRCERA methoxy peg-epoetin beta SYRINGE 30 mcg/0.3 mL N Y  
59353040109 MIRCERA methoxy peg-epoetin beta SYRINGE 50 mcg/0.3 mL N Y  
59353040209 MIRCERA methoxy peg-epoetin beta SYRINGE 75 mcg/0.3 mL N Y  
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