Vascular Endothelial Growth Factors

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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
61755000501 EYLEA aflibercept SYRINGE 2 mg/0.05 mL N Y PA Document
61755000554 EYLEA aflibercept SYRINGE 2 mg/0.05 mL N Y PA Document
61755000502 EYLEA aflibercept VIAL 2 mg/0.05 mL N Y PA Document
61755000555 EYLEA aflibercept VIAL 2 mg/0.05 mL N Y PA Document
61755005000 EYLEA HD aflibercept VIAL 8 mg/0.07 mL N Y PA Document
61755005001 EYLEA HD aflibercept VIAL 8 mg/0.07 mL N Y PA Document
61755005050 EYLEA HD aflibercept VIAL 8 mg/0.07 mL N Y PA Document
61755005051 EYLEA HD aflibercept VIAL 8 mg/0.07 mL N Y PA Document
55513005601 PAVBLU aflibercept-ayyh SYRINGE 2 mg/0.05 mL N Y PA Document
55513006501 PAVBLU aflibercept-ayyh VIAL 2 mg/0.05 mL N Y PA Document
50242006001 AVASTIN bevacizumab VIAL 25 mg/mL Y Y  
50242006101 AVASTIN bevacizumab VIAL 25 mg/mL Y Y  
00078082760 BEOVU brolucizumab-dbll SYRINGE 6 mg/0.05 mL N Y PA Document
50242009606 VABYSMO faricimab-svoa SYRINGE 6 mg/0.05 mL N Y PA Document
50242009601 VABYSMO faricimab-svoa VIAL 6 mg/0.05 mL N Y PA Document
50242009677 VABYSMO faricimab-svoa VIAL 6 mg/0.05 mL N Y PA Document
50242009686 VABYSMO faricimab-svoa VIAL 6 mg/0.05 mL N Y PA Document
50242008203 LUCENTIS ranibizumab SYRINGE 0.3 mg/0.05 mL N Y PA Document
50242008288 LUCENTIS ranibizumab SYRINGE 0.3 mg/0.05 mL N Y PA Document
50242008003 LUCENTIS ranibizumab SYRINGE 0.5 mg/0.05 mL N Y PA Document
50242008088 LUCENTIS ranibizumab SYRINGE 0.5 mg/0.05 mL N Y PA Document
50242008287 LUCENTIS ranibizumab VIAL 0.3 mg/0.05 mL N Y PA Document
50242008086 LUCENTIS ranibizumab VIAL 0.5 mg/0.05 mL N Y PA Document
50242007812 SUSVIMO ranibizumab VIAL 10 mg/0.1 mL N Y PA Document
61314062494 CIMERLI ranibizumab-eqrn VIAL 0.3 mg/0.05 mL N Y PA Document
70114044001 CIMERLI ranibizumab-eqrn VIAL 0.3 mg/0.05 mL N Y PA Document
61314062594 CIMERLI ranibizumab-eqrn VIAL 0.5 mg/0.05 mL N Y PA Document
70114044101 CIMERLI ranibizumab-eqrn VIAL 0.5 mg/0.05 mL N Y PA Document
64406001901 BYOOVIZ ranibizumab-nuna VIAL 0.5 mg/0.05 mL N Y PA Document
64406001907 BYOOVIZ ranibizumab-nuna VIAL 0.5 mg/0.05 mL N Y PA Document
50242007855 SUSVIMO ranibizumab/init fill needle VIAL 10 mg/0.1 mL N Y PA Document
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