Spinal Muscular Atrophy
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 |
|---|---|---|---|---|---|---|---|
| 64406005801 | SPINRAZA | nusinersen sodium/PF | VIAL | 12 mg/5 mL | N | Y | PA Document |
| 71894014611 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 10) | Y | Y | PA Document |
| 71894014912 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 11) | Y | Y | PA Document |
| 71894015213 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 12) | Y | Y | PA Document |
| 71894015514 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 13) | Y | Y | PA Document |
| 71894012203 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 2) | Y | Y | PA Document |
| 71894012504 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 3) | Y | Y | PA Document |
| 71894012805 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 4) | Y | Y | PA Document |
| 71894013106 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 5) | Y | Y | PA Document |
| 71894013407 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 6) | Y | Y | PA Document |
| 71894013708 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 7) | Y | Y | PA Document |
| 71894014009 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 8) | Y | Y | PA Document |
| 71894014310 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL and 8.3 mL x 9) | Y | Y | PA Document |
| 71894014812 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL x 10) | Y | Y | PA Document |
| 71894015113 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL x 11) | Y | Y | PA Document |
| 71894015414 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL x 12) | Y | Y | PA Document |
| 71894012404 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL x 2) | Y | Y | PA Document |
| 71894012705 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL x 3) | Y | Y | PA Document |
| 71894013006 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL x 4) | Y | Y | PA Document |
| 71894013307 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL x 5) | Y | Y | PA Document |
| 71894013608 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL x 6) | Y | Y | PA Document |
| 71894013909 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL x 7) | Y | Y | PA Document |
| 71894014210 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL x 8) | Y | Y | PA Document |
| 71894014511 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL x 9) | Y | Y | PA Document |
| 71894012103 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (5.5 mL x 2 and 8.3 mL) | Y | Y | PA Document |
| 71894014410 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 10) | Y | Y | PA Document |
| 71894014711 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 11) | Y | Y | PA Document |
| 71894015012 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 12) | Y | Y | PA Document |
| 71894015313 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 13) | Y | Y | PA Document |
| 71894015614 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 14) | Y | Y | PA Document |
| 71894012002 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 2) | Y | Y | PA Document |
| 71894012303 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 3) | Y | Y | PA Document |
| 71894012604 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 4) | Y | Y | PA Document |
| 71894012905 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 5) | Y | Y | PA Document |
| 71894013206 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 6) | Y | Y | PA Document |
| 71894013507 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 7) | Y | Y | PA Document |
| 71894013808 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 8) | Y | Y | PA Document |
| 71894014109 | ZOLGENSMA | onasemnogene abeparvovec-xioi | KIT | 2 x 10exp13 vector genomes/mL (8.3 mL x 9) | Y | Y | PA Document |
| 50242017505 | EVRYSDI | risdiplam | SOLN RECON | 0.75 mg/mL | N | Y | PA Document |
| 50242017507 | EVRYSDI | risdiplam | SOLN RECON | 0.75 mg/mL | N | Y | PA Document |
| 50242020201 | EVRYSDI | risdiplam | TABLET | 5 mg | N | Y | PA Document |