Hemophagocytic lymphohistiocytosis
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 |
|---|---|---|---|---|---|---|---|
| 66658050101 | GAMIFANT | emapalumab-lzsg | VIAL | 10 mg/2 mL (5 mg/mL) | N | Y | PA Document |
| 66658051001 | GAMIFANT | emapalumab-lzsg | VIAL | 100 mg/20 mL (5 mg/mL) | N | Y | PA Document |
| 66658050501 | GAMIFANT | emapalumab-lzsg | VIAL | 50 mg/10 mL (5 mg/mL) | N | Y | PA Document |