Allergens

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
00026994005 ALBAY hymenoptera allergenic extract VIAL 100 mcg/mL Y  
00026994105 ALBAY hymenoptera allergenic extract VIAL 100 mcg/mL Y  
00026994205 ALBAY hymenoptera allergenic extract VIAL 100 mcg/mL Y  
00026994405 ALBAY hymenoptera allergenic extract VIAL 100 mcg/mL Y  
00026994011 VENOMIL INDIVIDUAL DIAGNOSTIC hymenoptera allergenic extract VIAL 12 mcg Y  
00026994111 VENOMIL INDIVIDUAL DIAGNOSTIC hymenoptera allergenic extract VIAL 12 mcg Y  
00026994211 VENOMIL INDIVIDUAL DIAGNOSTIC hymenoptera allergenic extract VIAL 12 mcg Y  
00026994411 VENOMIL INDIVIDUAL DIAGNOSTIC hymenoptera allergenic extract VIAL 12 mcg Y  
00026994012 VENOMIL MAINTENANCE hymenoptera allergenic extract VIAL 120 mcg Y  
00026994112 VENOMIL MAINTENANCE hymenoptera allergenic extract VIAL 120 mcg Y  
00026994212 VENOMIL MAINTENANCE hymenoptera allergenic extract VIAL 120 mcg Y  
00026994412 VENOMIL MAINTENANCE hymenoptera allergenic extract VIAL 120 mcg Y  
00026994505 ALBAY hymenoptera allergenic extract VIAL 300 mcg/mL Y  
00026994512 VENOMIL MAINTENANCE hymenoptera allergenic extract VIAL 360 mcg Y  
00026996600 DERMATOPHYTIN O mold extracts ALLERGEN Y  
00026995100 POLLEN EXTRACT, NON-GLYCER pollen extracts ALLERGEN 1:10 Y  
00026995000 POLLEN EXTRACT, GLYCERINATED pollen extracts ALLERGEN 1:20 Y  
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