Sickle Cell Disease
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 |
|---|---|---|---|---|---|---|---|
| 00078088361 | ADAKVEO | crizanlizumab-tmca | VIAL | 100 mg/10 mL (10 mg/mL) | N | Y | PA Document |
| 42457042001 | ENDARI | glutamine | POWD PACK | 5 gram | N | Y | PA Document |
| 42457042060 | ENDARI | glutamine | POWD PACK | 5 gram | N | Y | PA Document |
| 70954041710 | L-GLUTAMINE | glutamine | POWD PACK | 5 gram | N | Y | PA Document |
| 70954041720 | L-GLUTAMINE | glutamine | POWD PACK | 5 gram | N | Y | PA Document |
| 61269040260 | DROXIA | hydroxyurea | CAPSULE | 200 mg | N | Y | |
| 61269040360 | DROXIA | hydroxyurea | CAPSULE | 300 mg | N | Y | |
| 61269040460 | DROXIA | hydroxyurea | CAPSULE | 400 mg | N | Y | |
| 61269083510 | HYDREA | hydroxyurea | CAPSULE | 500 mg | Y | Y | |
| 00555088202 | HYDROXYUREA | hydroxyurea | CAPSULE | 500 mg | Y | Y | |
| 00904693961 | HYDROXYUREA | hydroxyurea | CAPSULE | 500 mg | Y | Y | |
| 49884072401 | HYDROXYUREA | hydroxyurea | CAPSULE | 500 mg | Y | Y | |
| 51285054802 | HYDROXYUREA | hydroxyurea | CAPSULE | 500 mg | Y | Y | |
| 68084028401 | HYDROXYUREA | hydroxyurea | CAPSULE | 500 mg | Y | Y | |
| 68084028411 | HYDROXYUREA | hydroxyurea | CAPSULE | 500 mg | Y | Y | |
| 69315016401 | HYDROXYUREA | hydroxyurea | CAPSULE | 500 mg | Y | Y | |
| 70069082001 | HYDROXYUREA | hydroxyurea | CAPSULE | 500 mg | Y | Y | |
| 62484001504 | XROMI | hydroxyurea | SOLUTION | 100 mg/mL | N | Y | |
| 62484001505 | XROMI | hydroxyurea | SOLUTION | 100 mg/mL | N | Y | |
| 71770012030 | SIKLOS | hydroxyurea | TABLET | 1,000 mg | N | Y | |
| 71770010560 | SIKLOS | hydroxyurea | TABLET | 100 mg | N | Y |