Coronavirus Antivirals
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 |
|---|---|---|---|---|---|---|---|
| 00006505506 | LAGEVRIO (EUA) | molnupiravir | CAPSULE | 200 mg | Y | ||
| 00006505509 | LAGEVRIO (EUA) | molnupiravir | CAPSULE | 200 mg | Y | ||
| 00069531702 | PAXLOVID | nirmatrelvir/ritonavir | TAB DS PK | 150 mg (10)-100 mg (10) | Y | Y | |
| 00069531720 | PAXLOVID | nirmatrelvir/ritonavir | TAB DS PK | 150 mg (10)-100 mg (10) | Y | Y | |
| 00069543402 | PAXLOVID | nirmatrelvir/ritonavir | TAB DS PK | 150 mg (10)-100 mg (10) | Y | Y | |
| 00069543420 | PAXLOVID | nirmatrelvir/ritonavir | TAB DS PK | 150 mg (10)-100 mg (10) | Y | Y | |
| 00069110104 | PAXLOVID (EUA) | nirmatrelvir/ritonavir | TAB DS PK | 150 mg (10)-100 mg (10) | Y | Y | |
| 00069110120 | PAXLOVID (EUA) | nirmatrelvir/ritonavir | TAB DS PK | 150 mg (10)-100 mg (10) | Y | Y | |
| 00069052111 | PAXLOVID | nirmatrelvir/ritonavir | TAB DS PK | 150 mg (6)-100 mg (5) | Y | Y | |
| 00069504506 | PAXLOVID | nirmatrelvir/ritonavir | TAB DS PK | 300 mg (150 mg x 2)-100 mg | Y | Y | |
| 00069504530 | PAXLOVID | nirmatrelvir/ritonavir | TAB DS PK | 300 mg (150 mg x 2)-100 mg | Y | Y | |
| 00069532103 | PAXLOVID | nirmatrelvir/ritonavir | TAB DS PK | 300 mg (150 mg x 2)-100 mg | Y | Y | |
| 00069532130 | PAXLOVID | nirmatrelvir/ritonavir | TAB DS PK | 300 mg (150 mg x 2)-100 mg | Y | Y | |
| 00069034506 | PAXLOVID (EUA) | nirmatrelvir/ritonavir | TAB DS PK | 300 mg (150 mg x 2)-100 mg | Y | Y | |
| 00069034530 | PAXLOVID (EUA) | nirmatrelvir/ritonavir | TAB DS PK | 300 mg (150 mg x 2)-100 mg | Y | Y | |
| 00069108506 | PAXLOVID (EUA) | nirmatrelvir/ritonavir | TAB DS PK | 300 mg (150 mg x 2)-100 mg | Y | Y | |
| 00069108530 | PAXLOVID (EUA) | nirmatrelvir/ritonavir | TAB DS PK | 300 mg (150 mg x 2)-100 mg | Y | Y | |
| 61958290102 | VEKLURY | remdesivir | VIAL | 100 mg | Y | Y |