Immunotherapy Desensitization, non-injectable

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
59617001001 ORALAIR gr pol-orc/sw ver/rye/Kent/tim TAB SUBL 100 index of reactivity N Y PA Document
59617002001 ORALAIR gr pol-orc/sw ver/rye/Kent/tim TAB SUBL 100 Index of Reactivity (3)/300 Index of Reactivity (6) N Y PA Document
59617001502 ORALAIR gr pol-orc/sw ver/rye/Kent/tim TAB SUBL 300 index of reactivity N Y PA Document
59617001503 ORALAIR gr pol-orc/sw ver/rye/Kent/tim TAB SUBL 300 index of reactivity N Y PA Document
59617001601 ORALAIR gr pol-orc/sw ver/rye/Kent/tim TAB SUBL 300 index of reactivity N Y PA Document
59617002501 ORALAIR gr pol-orc/sw ver/rye/Kent/tim TAB SUBL 300 index of reactivity N Y PA Document
52709150101 GRASTEK grass pollen-timothy, standard TAB SUBL 2,800 bioequivalent allergy unit N Y PA Document
52709150103 GRASTEK grass pollen-timothy, standard TAB SUBL 2,800 bioequivalent allergy unit N Y PA Document
52709170101 ODACTRA mite,D.farinae-D.pteronyssinus TAB SUBL 12 standardized quality-house dust mite N Y PA Document
52709170103 ODACTRA mite,D.farinae-D.pteronyssinus TAB SUBL 12 standardized quality-house dust mite N Y PA Document
71881011313 PALFORZIA peanut allergen powder-dnfp CAP SPRINK 0.5 mg/1 mg/1.5 mg/3 mg/6 mg N Y PA Document
71881010345 PALFORZIA peanut allergen powder-dnfp CAP SPRINK 12 mg (1 mg x 2, 10 mg x 1) N Y PA Document
71881010730 PALFORZIA peanut allergen powder-dnfp CAP SPRINK 120 mg (20 mg x 1, 100 mg x 1) N Y PA Document
71881010860 PALFORZIA peanut allergen powder-dnfp CAP SPRINK 160 mg (20 mg x 3, 100 mg x 1) N Y PA Document
71881010415 PALFORZIA peanut allergen powder-dnfp CAP SPRINK 20 mg N Y PA Document
71881010930 PALFORZIA peanut allergen powder-dnfp CAP SPRINK 200 mg (100 mg x 2) N Y PA Document
71881011060 PALFORZIA peanut allergen powder-dnfp CAP SPRINK 240 mg (20 mg x 2, 100 mg x 2) N Y PA Document
71881010145 PALFORZIA peanut allergen powder-dnfp CAP SPRINK 3 mg (1 mg x 3) N Y PA Document
71881010530 PALFORZIA peanut allergen powder-dnfp CAP SPRINK 40 mg (20 mg x 2) N Y PA Document
71881010290 PALFORZIA peanut allergen powder-dnfp CAP SPRINK 6 mg (1 mg x 6) N Y PA Document
71881010660 PALFORZIA peanut allergen powder-dnfp CAP SPRINK 80 mg (20 mg x 4) N Y PA Document
71881011115 PALFORZIA peanut allergen powder-dnfp POWD PACK 300 mg N Y PA Document
71881011130 PALFORZIA peanut allergen powder-dnfp POWD PACK 300 mg N Y PA Document
52709160101 RAGWITEK weed pollen-short ragweed TAB SUBL 12 Amb a 1 unit N Y PA Document
52709160103 RAGWITEK weed pollen-short ragweed TAB SUBL 12 Amb a 1 unit N Y PA Document
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