Monoclonal Antibodies for Lupus
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 |
|---|---|---|---|---|---|---|---|
| 00310304000 | SAPHNELO | anifrolumab-fnia | VIAL | 300 mg/2 mL (150 mg/mL) | N | Y | PA Document |
| 49401008801 | BENLYSTA | belimumab | AUTO INJCT | 200 mg/mL | N | Y | PA Document |
| 49401008835 | BENLYSTA | belimumab | AUTO INJCT | 200 mg/mL | N | Y | PA Document |
| 49401008861 | BENLYSTA | belimumab | AUTO INJCT | 200 mg/mL | N | Y | PA Document |
| 49401008842 | BENLYSTA | belimumab | SYRINGE | 200 mg/mL | N | Y | PA Document |
| 49401008847 | BENLYSTA | belimumab | SYRINGE | 200 mg/mL | N | Y | PA Document |
| 49401010101 | BENLYSTA | belimumab | VIAL | 120 mg | N | Y | PA Document |
| 49401010201 | BENLYSTA | belimumab | VIAL | 400 mg | N | Y | PA Document |