Pulmonary Arterial Hypertension Parenteral Drugs
PDL Reference Documents
Drug Use Review 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 |
|---|---|---|---|---|---|---|---|
| 62756005940 | EPOPROSTENOL SODIUM | epoprostenol sodium | VIAL | 0.5 mg | N | Y | PA Document |
| 67457058710 | EPOPROSTENOL SODIUM | epoprostenol sodium | VIAL | 0.5 mg | N | Y | PA Document |
| 66215040301 | VELETRI | epoprostenol sodium | VIAL | 0.5 mg | N | Y | PA Document |
| 62756006040 | EPOPROSTENOL SODIUM | epoprostenol sodium | VIAL | 1.5 mg | N | Y | PA Document |
| 67457058810 | EPOPROSTENOL SODIUM | epoprostenol sodium | VIAL | 1.5 mg | N | Y | PA Document |
| 66215040201 | VELETRI | epoprostenol sodium | VIAL | 1.5 mg | N | Y | PA Document |
| 00173051700 | FLOLAN | epoprostenol sodium (glycine) | VIAL | 0.5 mg | Y | Y | |
| 00173051900 | FLOLAN | epoprostenol sodium (glycine) | VIAL | 1.5 mg | Y | Y | |
| 66215071801 | UPTRAVI | selexipag | VIAL | 1,800 mcg | N | Y | PA Document |
| 00069033801 | REVATIO | sildenafil citrate | VIAL | 10 mg/12.5 mL | N | Y | PA Document |
| 58151039531 | REVATIO | sildenafil citrate | VIAL | 10 mg/12.5 mL | N | Y | PA Document |
| 55150016613 | SILDENAFIL CITRATE | sildenafil citrate | VIAL | 10 mg/12.5 mL | N | Y | PA Document |
| 00006508801 | WINREVAIR (2 PACK) | sotatercept-csrk | KIT | 120 mg (60 mg x 2) | N | Y | PA Document |
| 00006506899 | WINREVAIR | sotatercept-csrk | KIT | 45 mg | N | Y | PA Document |
| 00006509001 | WINREVAIR | sotatercept-csrk | KIT | 45 mg | N | Y | PA Document |
| 00006506999 | WINREVAIR | sotatercept-csrk | KIT | 60 mg | N | Y | PA Document |
| 00006509101 | WINREVAIR | sotatercept-csrk | KIT | 60 mg | N | Y | PA Document |
| 00006508701 | WINREVAIR (2 PACK) | sotatercept-csrk | KIT | 90 mg (45 mg x 2) | N | Y | PA Document |
| 66302011401 | REMODULIN | treprostinil sodium | VIAL | 0.4 mg/mL | Y | ||
| 66302010101 | REMODULIN | treprostinil sodium | VIAL | 1 mg/mL | N | Y | PA Document |
| 00703066601 | TREPROSTINIL | treprostinil sodium | VIAL | 1 mg/mL | N | Y | PA Document |
| 00781342080 | TREPROSTINIL | treprostinil sodium | VIAL | 1 mg/mL | N | Y | PA Document |
| 43598064911 | TREPROSTINIL | treprostinil sodium | VIAL | 1 mg/mL | N | Y | PA Document |
| 66302011001 | REMODULIN | treprostinil sodium | VIAL | 10 mg/mL | N | Y | PA Document |
| 00703069601 | TREPROSTINIL | treprostinil sodium | VIAL | 10 mg/mL | N | Y | PA Document |
| 00781343080 | TREPROSTINIL | treprostinil sodium | VIAL | 10 mg/mL | N | Y | PA Document |
| 43598064811 | TREPROSTINIL | treprostinil sodium | VIAL | 10 mg/mL | N | Y | PA Document |
| 66302010201 | REMODULIN | treprostinil sodium | VIAL | 2.5 mg/mL | N | Y | PA Document |
| 00703067601 | TREPROSTINIL | treprostinil sodium | VIAL | 2.5 mg/mL | N | Y | PA Document |
| 00781342580 | TREPROSTINIL | treprostinil sodium | VIAL | 2.5 mg/mL | N | Y | PA Document |
| 43598064611 | TREPROSTINIL | treprostinil sodium | VIAL | 2.5 mg/mL | N | Y | PA Document |
| 66302010501 | REMODULIN | treprostinil sodium | VIAL | 5 mg/mL | N | Y | PA Document |
| 00703068601 | TREPROSTINIL | treprostinil sodium | VIAL | 5 mg/mL | N | Y | PA Document |
| 00781342780 | TREPROSTINIL | treprostinil sodium | VIAL | 5 mg/mL | N | Y | PA Document |
| 43598064711 | TREPROSTINIL | treprostinil sodium | VIAL | 5 mg/mL | N | Y | PA Document |