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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
64764013501 ADZYNMA ADAMTS13, recombinant-krhn KIT 1,500 (+/-) unit range Y PA Document
64764014505 ADZYNMA ADAMTS13, recombinant-krhn KIT 1,500 (+/-) unit range Y PA Document
64764013001 ADZYNMA ADAMTS13, recombinant-krhn KIT 500 (+/-) unit range Y PA Document
64764014005 ADZYNMA ADAMTS13, recombinant-krhn KIT 500 (+/-) unit range Y PA Document
00078117519 VIJOICE alpelisib GRAN PACK 50 mg Y PA Document
00078117551 VIJOICE alpelisib GRAN PACK 50 mg Y PA Document
00078102884 VIJOICE alpelisib TABLET 125 mg Y PA Document
00078103502 VIJOICE alpelisib TABLET 250 mg/day (200 mg x 1 and 50 mg x 1) Y PA Document
00078103561 VIJOICE alpelisib TABLET 250 mg/day (200 mg x 1 and 50 mg x 1) Y PA Document
00078102151 VIJOICE alpelisib TABLET 50 mg Y PA Document
00078102184 VIJOICE alpelisib TABLET 50 mg Y PA Document
72542012401 MIPLYFFA arimoclomol citrate CAPSULE 124 mg Y PA Document
72542014701 MIPLYFFA arimoclomol citrate CAPSULE 47 mg Y PA Document
72542016201 MIPLYFFA arimoclomol citrate CAPSULE 62 mg Y PA Document
72542019301 MIPLYFFA arimoclomol citrate CAPSULE 93 mg Y PA Document
83222020001 LENMELDY atidarsagene autotemcel PLAST. BAG 2 x 10exp6 to 11.8 x 10exp6 cell/mL Y PA Document
73556016801 TAVNEOS avacopan CAPSULE 10 mg Y PA Document
73556016802 TAVNEOS avacopan CAPSULE 10 mg Y PA Document
50881002311 NIKTIMVO axatilimab-csfr VIAL 22 mg/0.44 mL Y PA Document
50881003412 NIKTIMVO axatilimab-csfr VIAL 9 mg/0.18 mL Y PA Document
79802020030 REZUROCK belumosudil mesylate TABLET 200 mg N Y PA Document
82194050101 VYJUVEK beremagene geperpavec-svdt GEL (ML) 5 x 10exp9 PFU/2.5 mL Y PA Document
82194051002 VYJUVEK beremagene geperpavec-svdt GEL (ML) 5 x 10exp9 PFU/2.5 mL Y PA Document
10122031001 FILSUVEZ birch bark extract GEL (GRAM) 10 % Y PA Document
10122031002 FILSUVEZ birch bark extract GEL (GRAM) 10 % Y PA Document
76431031001 FILSUVEZ birch bark extract GEL (GRAM) 10 % Y PA Document
42747010201 CRYSVITA burosumab-twza VIAL 10 mg/mL Y PA Document
42747020301 CRYSVITA burosumab-twza VIAL 20 mg/mL Y PA Document
42747030401 CRYSVITA burosumab-twza VIAL 30 mg/mL Y PA Document
68135081102 BRINEURA cerliponase alfa KIT 300 mg/10 mL (150 mg/5 mL X 2) Y PA Document
68135050000 BRINEURA cerliponase alfa VIAL 150 mg/5 mL Y PA Document
68974087640 CHENODAL chenodiol TABLET 250 mg Y PA Document
79378031090 CTEXLI chenodiol TABLET 250 mg Y PA Document
70370510001 CRENESSITY crinecerfont CAPSULE 100 mg Y PA Document
70370502501 CRENESSITY crinecerfont CAPSULE 25 mg Y PA Document
70370505001 CRENESSITY crinecerfont CAPSULE 50 mg Y PA Document
70370525001 CRENESSITY crinecerfont SOLUTION 50 mg/mL Y PA Document
50242011501 PIASKY crovalimab-akkz VIAL 340 mg/2 mL Y PA Document
25682004392 VOYDEYA danicopan TABLET 100 mg Y PA Document
25682004692 VOYDEYA danicopan TABLET 150 mg (50 mg x 1 and 100 mg x 1) Y PA Document
25682000101 SOLIRIS eculizumab VIAL 300 mg/30 mL Y PA Document
51759020813 EPYSQLI eculizumab-aagh VIAL 300 mg/30 mL N Y PA Document
55513018001 BKEMV eculizumab-aeeb VIAL 300 mg/30 mL N Y PA Document
52856060101 KEBILIDI eladocagene exuparvovec-tneq VIAL 2.8 x 10exp11 vector genomes/0.5 mL Y PA Document
52856060111 KEBILIDI eladocagene exuparvovec-tneq VIAL 2.8 x 10exp11 vector genomes/0.5 mL Y PA Document
15054008001 IQIRVO elafibranor TABLET 80 mg Y PA Document
10122050201 REVCOVI elapegademase-lvlr VIAL 2.4 mg/1.5 mL (1.6 mg/mL) Y PA Document
73554211101 SKYSONA elivaldogene autotemcel PLAST. BAG 4 x 10exp6 to 30 x 10exp6 cell/mL Y PA Document
42358029501 NULIBRY fosdenopterin hydrobromide VIAL 9.5 mg Y PA Document
71336100101 GIVLAARI givosiran sodium VIAL 189 mg/mL Y PA Document
75987015001 UPLIZNA inebilizumab-cdon VIAL 100 mg/10 mL (10 mg/mL) Y PA Document
75987015003 UPLIZNA inebilizumab-cdon VIAL 100 mg/10 mL (10 mg/mL) Y PA Document
00078118920 FABHALTA iptacopan HCl CAPSULE 200 mg N Y PA Document
71274017060 JOENJA leniolisib phosphate TABLET 70 mg Y PA Document
83853010101 AQNEURSA levacetylleucine GRAN PACK 1 gram Y PA Document
72065000301 RECORLEV levoketoconazole TABLET 150 mg Y PA Document
42358045030 ZOKINVY lonafarnib CAPSULE 50 mg Y PA Document
73079005030 ZOKINVY lonafarnib CAPSULE 50 mg Y PA Document
42358047530 ZOKINVY lonafarnib CAPSULE 75 mg Y PA Document
73079007530 ZOKINVY lonafarnib CAPSULE 75 mg Y PA Document
71336100201 OXLUMO lumasiran sodium VIAL 94.5 mg/0.5 mL Y PA Document
59572071101 REBLOZYL luspatercept-aamt VIAL 25 mg Y PA Document
59572077501 REBLOZYL luspatercept-aamt VIAL 75 mg Y PA Document
79378011101 LIVMARLI maralixibat chloride SOLUTION 19 mg/mL Y PA Document
79378011001 LIVMARLI maralixibat chloride SOLUTION 9.5 mg/mL Y PA Document
79378021030 LIVMARLI maralixibat chloride TABLET 10 mg Y PA Document
79378021530 LIVMARLI maralixibat chloride TABLET 15 mg Y PA Document
79378022030 LIVMARLI maralixibat chloride TABLET 20 mg Y PA Document
79378023030 LIVMARLI maralixibat chloride TABLET 30 mg Y PA Document
73625011311 CAMZYOS mavacamten CAPSULE 10 mg Y PA Document
73625011411 CAMZYOS mavacamten CAPSULE 15 mg Y PA Document
73625011111 CAMZYOS mavacamten CAPSULE 2.5 mg Y PA Document
73625011211 CAMZYOS mavacamten CAPSULE 5 mg Y PA Document
83296010012 XOLREMDI mavorixafor CAPSULE 100 mg Y PA Document
83296010060 XOLREMDI mavorixafor CAPSULE 100 mg Y PA Document
83296010090 XOLREMDI mavorixafor CAPSULE 100 mg Y PA Document
82448013042 GOMEKLI mirdametinib CAPSULE 1 mg Y PA Document
82448026042 GOMEKLI mirdametinib CAPSULE 2 mg Y PA Document
82448026084 GOMEKLI mirdametinib CAPSULE 2 mg Y PA Document
82448013442 GOMEKLI mirdametinib TAB SUSP 1 mg Y PA Document
82448013484 GOMEKLI mirdametinib TAB SUSP 1 mg Y PA Document
71334022512 PYRUKYND mitapivat sulfate TAB DS PK 20 mg (7)-5 mg (7) Y PA Document
71334023013 PYRUKYND mitapivat sulfate TAB DS PK 50 mg (7)-20 mg (7) Y PA Document
71334021007 PYRUKYND mitapivat sulfate TABLET 20 mg Y PA Document
71334021014 PYRUKYND mitapivat sulfate TABLET 20 mg Y PA Document
71334021020 PYRUKYND mitapivat sulfate TABLET 20 mg Y PA Document
71334020505 PYRUKYND mitapivat sulfate TABLET 5 mg Y PA Document
71334020507 PYRUKYND mitapivat sulfate TABLET 5 mg Y PA Document
71334020514 PYRUKYND mitapivat sulfate TABLET 5 mg Y PA Document
71334022011 PYRUKYND mitapivat sulfate TABLET 5 mg Y PA Document
71334021507 PYRUKYND mitapivat sulfate TABLET 50 mg Y PA Document
71334021514 PYRUKYND mitapivat sulfate TABLET 50 mg Y PA Document
71334021550 PYRUKYND mitapivat sulfate TABLET 50 mg Y PA Document
00169530708 RIVFLOZA nedosiran sodium SYRINGE 128 mg/0.8 mL Y PA Document
00169530610 RIVFLOZA nedosiran sodium SYRINGE 160 mg/mL Y PA Document
00169530801 RIVFLOZA nedosiran sodium VIAL 80 mg/0.5 mL (160 mg/mL) Y PA Document
57894080101 IMAAVY nipocalimab-aahu VIAL 1,200 mg/6.5 mL (185 mg/mL) Y PA Document
15054330401 BYLVAY odevixibat CAPSULE 1,200 mcg Y PA Document
74528012001 BYLVAY odevixibat CAPSULE 1,200 mcg Y PA Document
15054330201 BYLVAY odevixibat CAPSULE 400 mcg Y PA Document
74528004001 BYLVAY odevixibat CAPSULE 400 mcg Y PA Document
15054330101 BYLVAY odevixibat PEL DSP CP 200 mcg Y PA Document
74528002001 BYLVAY odevixibat PEL DSP CP 200 mcg Y PA Document
15054330301 BYLVAY odevixibat PEL DSP CP 600 mcg Y PA Document
74528006001 BYLVAY odevixibat PEL DSP CP 600 mcg Y PA Document
58468005001 XENPOZYME olipudase alfa-rpcp VIAL 20 mg Y PA Document
58468005101 XENPOZYME olipudase alfa-rpcp VIAL 4 mg Y PA Document
73362010001 YORVIPATH palopegteriparatide PEN INJCTR 168 mcg teriparatide/0.56 mL Y PA Document
73362010002 YORVIPATH palopegteriparatide PEN INJCTR 168 mcg teriparatide/0.56 mL Y PA Document
73362010003 YORVIPATH palopegteriparatide PEN INJCTR 168 mcg teriparatide/0.56 mL Y PA Document
73362010101 YORVIPATH palopegteriparatide PEN INJCTR 294 mcg teriparatide/0.98 mL Y PA Document
73362010102 YORVIPATH palopegteriparatide PEN INJCTR 294 mcg teriparatide/0.98 mL Y PA Document
73362010103 YORVIPATH palopegteriparatide PEN INJCTR 294 mcg teriparatide/0.98 mL Y PA Document
73362010201 YORVIPATH palopegteriparatide PEN INJCTR 420 mcg teriparatide/1.4 mL Y PA Document
73362010202 YORVIPATH palopegteriparatide PEN INJCTR 420 mcg teriparatide/1.4 mL Y PA Document
73362010203 YORVIPATH palopegteriparatide PEN INJCTR 420 mcg teriparatide/1.4 mL Y PA Document
15054001001 SOHONOS palovarotene CAPSULE 1 mg Y PA Document
15054001501 SOHONOS palovarotene CAPSULE 1.5 mg Y PA Document
15054010001 SOHONOS palovarotene CAPSULE 10 mg Y PA Document
15054002501 SOHONOS palovarotene CAPSULE 2.5 mg Y PA Document
15054005001 SOHONOS palovarotene CAPSULE 5 mg Y PA Document
73606001001 EMPAVELI pegcetacoplan VIAL 1,080 mg/20 mL (54 mg/mL) Y PA Document
70573009901 RYPLAZIM plasminogen, human-tvmh VIAL 68.8 mg Y PA Document
70573009902 RYPLAZIM plasminogen, human-tvmh VIAL 68.8 mg Y PA Document
61755001400 VEOPOZ pozelimab-bbfg VIAL 400 mg/2 mL (200 mg/mL) Y PA Document
61755001401 VEOPOZ pozelimab-bbfg VIAL 400 mg/2 mL (200 mg/mL) Y PA Document
25682002801 ULTOMIRIS ravulizumab-cwvz VIAL 1,100 mg/11 mL (100 mg/mL) Y PA Document
25682002501 ULTOMIRIS ravulizumab-cwvz VIAL 300 mg/3 mL (100 mg/mL) Y PA Document
73648011101 RYONCIL remestemcel-L-rknd KIT 6.68 x 10exp6 cell/mL (3.8 mL x 1) Y PA Document
73648011202 RYONCIL remestemcel-L-rknd KIT 6.68 x 10exp6 cell/mL (3.8 mL x 2) Y PA Document
73648011303 RYONCIL remestemcel-L-rknd KIT 6.68 x 10exp6 cell/mL (3.8 mL x 3) Y PA Document
73648011401 RYONCIL remestemcel-L-rknd KIT 6.68 x 10exp6 cell/mL (3.8 mL x 4) Y PA Document
73648011502 RYONCIL remestemcel-L-rknd KIT 6.68 x 10exp6 cell/mL (3.8 mL x 5) Y PA Document
73648011603 RYONCIL remestemcel-L-rknd KIT 6.68 x 10exp6 cell/mL (3.8 mL x 6) Y PA Document
73648011704 RYONCIL remestemcel-L-rknd KIT 6.68 x 10exp6 cell/mL (3.8 mL x 7) Y PA Document
73648011802 RYONCIL remestemcel-L-rknd KIT 6.68 x 10exp6 cell/mL (3.8 mL x 8) Y PA Document
73648015401 RYONCIL remestemcel-L-rknd VIAL 6.68 x 10exp6 cell/mL Y PA Document
73648015404 RYONCIL remestemcel-L-rknd VIAL 6.68 x 10exp6 cell/mL Y PA Document
70842024001 REZZAYO rezafungin acetate VIAL 200 mg Y PA Document
50474098079 RYSTIGGO rozanolixizumab-noli VIAL 280 mg/2 mL (140 mg/mL) Y PA Document
50474098183 RYSTIGGO rozanolixizumab-noli VIAL 420 mg/3 mL (140 mg/mL) Y PA Document
50474098284 RYSTIGGO rozanolixizumab-noli VIAL 560 mg/4 mL (140 mg/mL) Y PA Document
50474098386 RYSTIGGO rozanolixizumab-noli VIAL 840 mg/6 mL (140 mg/mL) Y PA Document
50242000701 ENSPRYNG satralizumab-mwge SYRINGE 120 mg/mL Y PA Document
61958330101 LIVDELZI seladelpar lysine CAPSULE 10 mg Y PA Document
73077001001 PEDMARK sodium thiosulfate VIAL 12.5 gram/100 mL (125 mg/mL) Y PA Document
80203034701 ENJAYMO sutimlimab-jome VIAL 1,100 mg/22 mL (50 mg/mL) Y PA Document
64406010901 QALSODY tofersen VIAL 100 mg/15 mL (6.7 mg/mL) Y PA Document
81802000108 CUVRIOR trientine tetrahydrochloride TABLET 300 mg Y PA Document
81802000172 CUVRIOR trientine tetrahydrochloride TABLET 300 mg Y PA Document
10122018001 LAMZEDE velmanase alfa-tycv VIAL 10 mg Y PA Document
10122018002 LAMZEDE velmanase alfa-tycv VIAL 10 mg Y PA Document
50474099080 ZILBRYSQ zilucoplan sodium SYRINGE 16.6 mg/0.416 mL N Y PA Document
50474099180 ZILBRYSQ zilucoplan sodium SYRINGE 23 mg/0.574 mL N Y PA Document
50474099280 ZILBRYSQ zilucoplan sodium SYRINGE 32.4 mg/0.81 mL N Y PA Document
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