Amyloidosis Agents
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 |
|---|---|---|---|---|---|---|---|
| 82228071228 | ATTRUBY | acoramidis HCl | TABLET | 356 mg | N | Y | PA Document |
| 00310940001 | WAINUA | eplontersen sodium | AUTO INJCT | 45 mg/0.8 mL | N | Y | PA Document |
| 72126000701 | TEGSEDI | inotersen sodium | SYRINGE | 284 mg/1.5 mL | N | Y | PA Document |
| 72126000702 | TEGSEDI | inotersen sodium | SYRINGE | 284 mg/1.5 mL | N | Y | PA Document |
| 71336100001 | ONPATTRO | patisiran sodium,lipid complex | VIAL | 10 mg/5 mL (2 mg/mL) | N | Y | PA Document |
| 00069873001 | VYNDAMAX | tafamidis | CAPSULE | 61 mg | N | Y | PA Document |
| 00069873030 | VYNDAMAX | tafamidis | CAPSULE | 61 mg | N | Y | PA Document |
| 00069197512 | VYNDAQEL | tafamidis meglumine | CAPSULE | 20 mg | N | Y | PA Document |
| 00069197540 | VYNDAQEL | tafamidis meglumine | CAPSULE | 20 mg | N | Y | PA Document |
| 71336100301 | AMVUTTRA | vutrisiran sodium | SYRINGE | 25 mg/0.5 mL | N | Y | PA Document |