Duchenne Muscular Dystrophy
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 |
|---|---|---|---|---|---|---|---|
| 60923022702 | AMONDYS-45 | casimersen | VIAL | 100 mg/2 mL (50 mg/mL) | N | Y | PA Document |
| 27808024901 | DEFLAZACORT | deflazacort | ORAL SUSP | 22.75 mg/mL | N | Y | PA Document |
| 52856050522 | EMFLAZA | deflazacort | ORAL SUSP | 22.75 mg/mL | N | Y | PA Document |
| 00832081530 | DEFLAZACORT | deflazacort | TABLET | 18 mg | Y | Y | PA Document |
| 59651060030 | DEFLAZACORT | deflazacort | TABLET | 18 mg | Y | Y | PA Document |
| 70095004130 | DEFLAZACORT | deflazacort | TABLET | 18 mg | Y | Y | PA Document |
| 52856050203 | EMFLAZA | deflazacort | TABLET | 18 mg | Y | Y | PA Document |
| 70710175003 | JAYTHARI | deflazacort | TABLET | 18 mg | Y | Y | PA Document |
| 00832081630 | DEFLAZACORT | deflazacort | TABLET | 30 mg | Y | Y | PA Document |
| 59651060130 | DEFLAZACORT | deflazacort | TABLET | 30 mg | Y | Y | PA Document |
| 70095004230 | DEFLAZACORT | deflazacort | TABLET | 30 mg | Y | Y | PA Document |
| 52856050303 | EMFLAZA | deflazacort | TABLET | 30 mg | Y | Y | PA Document |
| 70710175103 | JAYTHARI | deflazacort | TABLET | 30 mg | Y | Y | PA Document |
| 00832081730 | DEFLAZACORT | deflazacort | TABLET | 36 mg | Y | Y | PA Document |
| 59651060230 | DEFLAZACORT | deflazacort | TABLET | 36 mg | Y | Y | PA Document |
| 70095004330 | DEFLAZACORT | deflazacort | TABLET | 36 mg | Y | Y | PA Document |
| 52856050403 | EMFLAZA | deflazacort | TABLET | 36 mg | Y | Y | PA Document |
| 70710175203 | JAYTHARI | deflazacort | TABLET | 36 mg | Y | Y | PA Document |
| 00832081411 | DEFLAZACORT | deflazacort | TABLET | 6 mg | Y | Y | PA Document |
| 59651059901 | DEFLAZACORT | deflazacort | TABLET | 6 mg | Y | Y | PA Document |
| 70095004001 | DEFLAZACORT | deflazacort | TABLET | 6 mg | Y | Y | PA Document |
| 52856050101 | EMFLAZA | deflazacort | TABLET | 6 mg | Y | Y | PA Document |
| 70710174901 | JAYTHARI | deflazacort | TABLET | 6 mg | Y | Y | PA Document |
| 60923050110 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 10) | N | Y | PA Document |
| 60923050211 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 11) | N | Y | PA Document |
| 60923050312 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 12) | N | Y | PA Document |
| 60923050413 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 13) | N | Y | PA Document |
| 60923050514 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 14) | N | Y | PA Document |
| 60923050615 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 15) | N | Y | PA Document |
| 60923050716 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 16) | N | Y | PA Document |
| 60923050817 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 17) | N | Y | PA Document |
| 60923050918 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 18) | N | Y | PA Document |
| 60923051019 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 19) | N | Y | PA Document |
| 60923051120 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 20) | N | Y | PA Document |
| 60923051221 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 21) | N | Y | PA Document |
| 60923051322 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 22) | N | Y | PA Document |
| 60923051423 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 23) | N | Y | PA Document |
| 60923051524 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 24) | N | Y | PA Document |
| 60923051625 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 25) | N | Y | PA Document |
| 60923051726 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 26) | N | Y | PA Document |
| 60923051827 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 27) | N | Y | PA Document |
| 60923051928 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 28) | N | Y | PA Document |
| 60923052029 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 29) | N | Y | PA Document |
| 60923052130 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 30) | N | Y | PA Document |
| 60923052231 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 31) | N | Y | PA Document |
| 60923052332 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 32) | N | Y | PA Document |
| 60923052433 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 33) | N | Y | PA Document |
| 60923052534 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 34) | N | Y | PA Document |
| 60923052635 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 35) | N | Y | PA Document |
| 60923052736 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 36) | N | Y | PA Document |
| 60923052837 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 37) | N | Y | PA Document |
| 60923052938 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 38) | N | Y | PA Document |
| 60923053039 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 39) | N | Y | PA Document |
| 60923053140 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 40) | N | Y | PA Document |
| 60923053241 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 41) | N | Y | PA Document |
| 60923053342 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 42) | N | Y | PA Document |
| 60923053443 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 43) | N | Y | PA Document |
| 60923053544 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 44) | N | Y | PA Document |
| 60923053645 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 45) | N | Y | PA Document |
| 60923053746 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 46) | N | Y | PA Document |
| 60923053847 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 47) | N | Y | PA Document |
| 60923053948 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 48) | N | Y | PA Document |
| 60923054049 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 49) | N | Y | PA Document |
| 60923054150 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 50) | N | Y | PA Document |
| 60923054251 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 51) | N | Y | PA Document |
| 60923054352 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 52) | N | Y | PA Document |
| 60923054453 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 53) | N | Y | PA Document |
| 60923054554 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 54) | N | Y | PA Document |
| 60923054655 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 55) | N | Y | PA Document |
| 60923054756 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 56) | N | Y | PA Document |
| 60923054857 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 57) | N | Y | PA Document |
| 60923054958 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 58) | N | Y | PA Document |
| 60923055059 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 59) | N | Y | PA Document |
| 60923055160 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 60) | N | Y | PA Document |
| 60923055261 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 61) | N | Y | PA Document |
| 60923055362 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 62) | N | Y | PA Document |
| 60923055463 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 63) | N | Y | PA Document |
| 60923055564 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 64) | N | Y | PA Document |
| 60923055665 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 65) | N | Y | PA Document |
| 60923055766 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 66) | N | Y | PA Document |
| 60923055867 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 67) | N | Y | PA Document |
| 60923055968 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 68) | N | Y | PA Document |
| 60923056069 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 69) | N | Y | PA Document |
| 60923056170 | ELEVIDYS | delandistrogene moxeparvc-rokl | KIT | 1.33 x 10exp13 vector genomes/mL (10 mL x 70) | N | Y | PA Document |
| 60923056201 | ELEVIDYS | delandistrogene moxeparvc-rokl | VIAL | 1.33 x 10exp13 vector genomes/mL | N | Y | PA Document |
| 60923036302 | EXONDYS-51 | eteplirsen | VIAL | 100 mg/2 mL (50 mg/mL) | N | Y | PA Document |
| 60923028410 | EXONDYS-51 | eteplirsen | VIAL | 500 mg/10 mL (50 mg/mL) | N | Y | PA Document |
| 11797011001 | DUVYZAT | givinostat hydrochloride | ORAL SUSP | 8.86 mg/mL | N | Y | PA Document |
| 11797011002 | DUVYZAT | givinostat hydrochloride | ORAL SUSP | 8.86 mg/mL | N | Y | PA Document |
| 60923046502 | VYONDYS-53 | golodirsen | VIAL | 100 mg/2 mL (50 mg/mL) | N | Y | PA Document |
| 69616026438 | AGAMREE | vamorolone | ORAL SUSP | 40 mg/mL | N | Y | PA Document |
| 73292001101 | VILTEPSO | viltolarsen | VIAL | 250 mg/5 mL (50 mg/mL) | N | Y | PA Document |