Epidermolysis Bullosa
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 | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 82194050101 | VYJUVEK | beremagene geperpavec-svdt | GEL (ML) | 5 x 10exp9 PFU/2.5 mL | Y | N | ||
| 82194051002 | VYJUVEK | beremagene geperpavec-svdt | GEL (ML) | 5 x 10exp9 PFU/2.5 mL | Y | N | ||
| 10122031001 | FILSUVEZ | birch bark extract | GEL (GRAM) | 10 % | Y | N | ||
| 10122031002 | FILSUVEZ | birch bark extract | GEL (GRAM) | 10 % | Y | N | ||
| 76431031001 | FILSUVEZ | birch bark extract | GEL (GRAM) | 10 % | Y | N | ||
| 84103000701 | ZEVASKYN | prademagene zamikeracel | SHEET | 5.5 cm X 7.5 cm | Y | N |