Endothelin Receptor Antagonists
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 |
|---|---|---|---|---|---|---|---|---|
| 80491801203 | TRYVIO | aprocitentan | TABLET | 12.5 mg | Y | Pharmacy PA | ||
| 00078142015 | VANRAFIA | atrasentan hydrochloride | TABLET | 0.75 mg | N | Y | Pharmacy PA | |
| 68974020030 | FILSPARI | sparsentan | TABLET | 200 mg | N | Y | Pharmacy PA | |
| 68974040030 | FILSPARI | sparsentan | TABLET | 400 mg | N | Y | Pharmacy PA |