Biologics for Rare Conditions
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 |
|---|---|---|---|---|---|---|---|
| 73475304105 | VYVGART | efgartigimod alfa-fcab | VIAL | 400 mg/20 mL (20 mg/mL) | N | Y | PA Document |
| 73475122101 | VYVGART HYTRULO | efgartigimod-hyaluronidas-qvfc | SYRINGE | 1,000 mg-10,000 unit/5 mL (200 mg-2,000 unit/mL) | Y | PA Document | |
| 73475122104 | VYVGART HYTRULO | efgartigimod-hyaluronidas-qvfc | SYRINGE | 1,000 mg-10,000 unit/5 mL (200 mg-2,000 unit/mL) | Y | PA Document | |
| 73475310203 | VYVGART HYTRULO | efgartigimod-hyaluronidas-qvfc | VIAL | 1,008 mg-11,200 unit/5.6 mL (180 mg-2,000 unit/mL) | Y | PA Document |