Influenza
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 50242082886 | XOFLUZA | baloxavir marboxil | TABLET | 20 mg | N | Y | PA Document |
| 50242086001 | XOFLUZA | baloxavir marboxil | TABLET | 40 mg | N | Y | PA Document |
| 50242086087 | XOFLUZA | baloxavir marboxil | TABLET | 40 mg | N | Y | PA Document |
| 50242087701 | XOFLUZA | baloxavir marboxil | TABLET | 80 mg | N | Y | PA Document |
| 00527459113 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 31722063031 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 33342025666 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 47781046813 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 60219126401 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 62332041310 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 64380079701 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 68180067511 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 69238126401 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 70710100802 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 72205004211 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 76282070245 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 00004080285 | TAMIFLU | oseltamivir phosphate | CAPSULE | 30 mg | Y | Y | Quantity Limit |
| 00527459213 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 31722063131 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 33342025766 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 47781046913 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 60219126501 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 62332041410 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 64380079801 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 68180067611 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 69238126501 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 70710100902 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 72205004311 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 76282070345 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 00004080185 | TAMIFLU | oseltamivir phosphate | CAPSULE | 45 mg | Y | Y | Quantity Limit |
| 00527459313 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 31722063231 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 33342025866 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 42806055501 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 47781047013 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 60219126601 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 62332041510 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 64380079901 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 68180067711 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 69238126601 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 70710101002 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 72205004411 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 76282070445 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 00004080007 | TAMIFLU | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 00004080008 | TAMIFLU | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 00004080085 | TAMIFLU | oseltamivir phosphate | CAPSULE | 75 mg | Y | Y | Quantity Limit |
| 00093818064 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 00527513762 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 27241013909 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 47781038426 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 59651059760 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 64380087975 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 68180067801 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 69097090443 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 69238127306 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 70710116506 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 72205006078 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 76282073952 | OSELTAMIVIR PHOSPHATE | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 00004082205 | TAMIFLU | oseltamivir phosphate | SUSP RECON | 6 mg/mL | Y | Y | Quantity Limit |
| 72769018101 | RAPIVAB | peramivir/PF | VIAL | 200 mg/20 mL (10 mg/mL) | Y | ||
| 72769018103 | RAPIVAB | peramivir/PF | VIAL | 200 mg/20 mL (10 mg/mL) | Y | ||
| 00115191101 | RIMANTADINE HCL | rimantadine HCl | TABLET | 100 mg | N | Y | PA Document |
| 00173068101 | RELENZA | zanamivir | BLST W/DEV | 5 mg | N | Y | PA Document |