Phenylketonuria

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
68135075619 PALYNZIQ pegvaliase-pqpz SYRINGE 10 mg/0.5 mL Y PA Document
68135075620 PALYNZIQ pegvaliase-pqpz SYRINGE 10 mg/0.5 mL Y PA Document
68135005889 PALYNZIQ pegvaliase-pqpz SYRINGE 2.5 mg/0.5 mL Y PA Document
68135005890 PALYNZIQ pegvaliase-pqpz SYRINGE 2.5 mg/0.5 mL Y PA Document
68135067339 PALYNZIQ pegvaliase-pqpz SYRINGE 20 mg/mL Y PA Document
68135067340 PALYNZIQ pegvaliase-pqpz SYRINGE 20 mg/mL Y PA Document
68135067345 PALYNZIQ pegvaliase-pqpz SYRINGE 20 mg/mL Y PA Document
43598009711 JAVYGTOR sapropterin dihydrochloride POWD PACK 100 mg Y PA Document
43598009730 JAVYGTOR sapropterin dihydrochloride POWD PACK 100 mg Y PA Document
68135030111 KUVAN sapropterin dihydrochloride POWD PACK 100 mg Y PA Document
68135030122 KUVAN sapropterin dihydrochloride POWD PACK 100 mg Y PA Document
31722004701 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 100 mg Y PA Document
31722004730 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 100 mg Y PA Document
49884094852 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 100 mg Y PA Document
49884094872 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 100 mg Y PA Document
72603019301 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 100 mg Y PA Document
72603019330 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 100 mg Y PA Document
43598016211 JAVYGTOR sapropterin dihydrochloride POWD PACK 500 mg Y PA Document
43598016230 JAVYGTOR sapropterin dihydrochloride POWD PACK 500 mg Y PA Document
68135048210 KUVAN sapropterin dihydrochloride POWD PACK 500 mg Y PA Document
68135048211 KUVAN sapropterin dihydrochloride POWD PACK 500 mg Y PA Document
31722004801 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 500 mg Y PA Document
31722004830 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 500 mg Y PA Document
49884087352 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 500 mg Y PA Document
49884087372 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 500 mg Y PA Document
72603019401 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 500 mg Y PA Document
72603019430 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride POWD PACK 500 mg Y PA Document
43598009604 JAVYGTOR sapropterin dihydrochloride TABLET SOL 100 mg N Y PA Document
68135030002 KUVAN sapropterin dihydrochloride TABLET SOL 100 mg N Y PA Document
31722004512 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride TABLET SOL 100 mg N Y PA Document
49884072008 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride TABLET SOL 100 mg N Y PA Document
59651057408 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride TABLET SOL 100 mg N Y PA Document
72603019101 SAPROPTERIN DIHYDROCHLORIDE sapropterin dihydrochloride TABLET SOL 100 mg N Y PA Document
52856030101 SEPHIENCE sepiapterin POWD PACK 1,000 mg N Y  
52856030103 SEPHIENCE sepiapterin POWD PACK 1,000 mg N Y  
52856020101 SEPHIENCE sepiapterin POWD PACK 250 mg N Y  
52856020103 SEPHIENCE sepiapterin POWD PACK 250 mg N Y  
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