Enzymes
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 |
|---|---|---|---|---|---|---|---|
| 66887000301 | XIAFLEX | collagenase Clostridium hist. | VIAL | 0.9 mg | Y | ||
| 00548909010 | AMPHADASE | hyaluronidase | VIAL | 150 unit/mL | Y | ||
| 00944272303 | HYQVIA HY COMPONENT | hyaluronidase, human recomb. | VIAL | 1,600 unit/10 mL | Y | ||
| 18657011701 | HYLENEX | hyaluronidase, human recomb. | VIAL | 150 unit/mL | Y | ||
| 18657011702 | HYLENEX | hyaluronidase, human recomb. | VIAL | 150 unit/mL | Y | ||
| 18657011704 | HYLENEX | hyaluronidase, human recomb. | VIAL | 150 unit/mL | Y | ||
| 00944272403 | HYQVIA HY COMPONENT | hyaluronidase, human recomb. | VIAL | 2,400 unit/15 mL | Y | ||
| 00944272003 | HYQVIA HY COMPONENT | hyaluronidase, human recomb. | VIAL | 200 unit/1.25 mL | Y | ||
| 00944272103 | HYQVIA HY COMPONENT | hyaluronidase, human recomb. | VIAL | 400 unit/2.5 mL | Y | ||
| 00944272203 | HYQVIA HY COMPONENT | hyaluronidase, human recomb. | VIAL | 800 unit/5 mL | Y | ||
| 24208000202 | VITRASE | hyaluronidase,ovine | VIAL | 200 unit/mL | Y |