Hereditary Angioedema
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 |
|---|---|---|---|---|---|---|---|
| 72769010201 | ORLADEYO | berotralstat hydrochloride | CAPSULE | 110 mg | N | Y | PA Document |
| 72769010101 | ORLADEYO | berotralstat hydrochloride | CAPSULE | 150 mg | N | Y | PA Document |
| 63833082502 | BERINERT | C1 esterase inhibitor | KIT | 500 unit (10 mL) | Y | Y | PA Document |
| 63833082802 | HAEGARDA | C1 esterase inhibitor | VIAL | 2,000 unit | Y | Y | PA Document |
| 63833082902 | HAEGARDA | C1 esterase inhibitor | VIAL | 3,000 unit | Y | Y | PA Document |
| 63833083501 | BERINERT | C1 esterase inhibitor | VIAL | 500 unit (10 mL) | Y | Y | PA Document |
| 42227008101 | CINRYZE | C1 esterase inhibitor | VIAL | 500 unit (5 mL) | N | Y | PA Document |
| 42227008301 | CINRYZE | C1 esterase inhibitor | VIAL | 500 unit (5 mL) | N | Y | PA Document |
| 71274035001 | RUCONEST | C1 esterase inhibitor, recomb | VIAL | 2,100 unit | N | Y | PA Document |
| 71274035002 | RUCONEST | C1 esterase inhibitor, recomb | VIAL | 2,100 unit | N | Y | PA Document |
| 71860010301 | DAWNZERA | donidalorsen sodium | AUTO INJCT | 80 mg/0.8 mL | Y | PA Document | |
| 47783010101 | KALBITOR | ecallantide | VIAL | 10 mg/mL (1 mL) | N | Y | PA Document |
| 54092070202 | FIRAZYR | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 54092070203 | FIRAZYR | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 00093306619 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 00093306634 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 00093306693 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 24201020701 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 54092013501 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 54092013502 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 55150035101 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 55150035103 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 60505621401 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 63323057401 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 63323057486 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 63323057493 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 69097066434 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 69097066468 | ICATIBANT | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 70709001301 | SAJAZIR | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 70709001303 | SAJAZIR | icatibant acetate | SYRINGE | 30 mg/3 mL | N | Y | PA Document |
| 47783064501 | TAKHZYRO | lanadelumab-flyo | SYRINGE | 150 mg/mL | N | Y | PA Document |
| 47783064601 | TAKHZYRO | lanadelumab-flyo | SYRINGE | 300 mg/2 mL (150 mg/mL) | N | Y | PA Document |
| 47783064401 | TAKHZYRO | lanadelumab-flyo | VIAL | 300 mg/2 mL (150 mg/mL) | N | Y | PA Document |