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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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 00069202501 | COMIRNATY | COVID-19 vac, tris(Pfizer)/PF | VIAL | 30 mcg/0.3 mL | Y | ||
| 00069202510 | COMIRNATY | COVID-19 vac, tris(Pfizer)/PF | VIAL | 30 mcg/0.3 mL | Y | ||
| 00069202525 | COMIRNATY | COVID-19 vac, tris(Pfizer)/PF | VIAL | 30 mcg/0.3 mL | Y | ||
| 59676058005 | JANSSEN COVID-19 VACCINE (EUA) | COVID-19 vac,Ad26(Janssen)/PF | VIAL | 0.5 mL | Y | ||
| 59676058015 | JANSSEN COVID-19 VACCINE (EUA) | COVID-19 vac,Ad26(Janssen)/PF | VIAL | 0.5 mL | Y | ||
| 49591053250 | CYTOGAM | cytomegalovirus immune globuln | VIAL | 50 mg/mL | Y | ||
| 49591053251 | CYTOGAM | cytomegalovirus immune globuln | VIAL | 50 mg/mL | Y | ||
| 49591005211 | HEPAGAM B | hepatitis B immun glob/maltose | VIAL | greater than 312 unit/mL | Y | ||
| 49591005251 | HEPAGAM B | hepatitis B immun glob/maltose | VIAL | greater than 312 unit/mL | Y | ||
| 70257005211 | HEPAGAM B | hepatitis B immun glob/maltose | VIAL | greater than 312 unit/mL | Y | ||
| 70257005251 | HEPAGAM B | hepatitis B immun glob/maltose | VIAL | greater than 312 unit/mL | Y | ||
| 49591005105 | HEPAGAM B | hepatitis B immun glob/maltose | VIAL | greater than 312 unit/mL (5 mL) | Y | ||
| 49591005151 | HEPAGAM B | hepatitis B immun glob/maltose | VIAL | greater than 312 unit/mL (5 mL) | Y | ||
| 70257005105 | HEPAGAM B | hepatitis B immun glob/maltose | VIAL | greater than 312 unit/mL (5 mL) | Y | ||
| 70257005151 | HEPAGAM B | hepatitis B immun glob/maltose | VIAL | greater than 312 unit/mL (5 mL) | Y | ||
| 13533063603 | HYPERHEP B | hepatitis B immune globulin | SYRINGE | 110 unit/0.5 mL | Y | ||
| 13533063630 | HYPERHEP B | hepatitis B immune globulin | SYRINGE | 110 unit/0.5 mL | Y | ||
| 13533063601 | HYPERHEP B | hepatitis B immune globulin | VIAL | 220 unit/mL | Y | ||
| 13533063610 | HYPERHEP B | hepatitis B immune globulin | VIAL | 220 unit/mL | Y | ||
| 13533063605 | HYPERHEP B | hepatitis B immune globulin | VIAL | 220 unit/mL (5 mL) | Y | ||
| 13533063650 | HYPERHEP B | hepatitis B immune globulin | VIAL | 220 unit/mL (5 mL) | Y | ||
| 69800420301 | NABI-HB | hepatitis B immune globulin | VIAL | greater than 1,560 unit/5 mL | Y | ||
| 69800420302 | NABI-HB | hepatitis B immune globulin | VIAL | greater than 1,560 unit/5 mL | Y | ||
| 69800420201 | NABI-HB | hepatitis B immune globulin | VIAL | greater than 312 unit/mL | Y | ||
| 69800420202 | NABI-HB | hepatitis B immune globulin | VIAL | greater than 312 unit/mL | Y | ||
| 00071449903 | HISTOPLASMIN | histoplasmin | VIAL | Y | |||
| 61476010401 | ALYGLO | immune globulin,gamma(IgG)stwk | VIAL | 10 % | N | Y | |
| 61476010402 | ALYGLO | immune globulin,gamma(IgG)stwk | VIAL | 10 % | N | Y | |
| 61476010403 | ALYGLO | immune globulin,gamma(IgG)stwk | VIAL | 10 % | N | Y | |
| 61476010405 | ALYGLO | immune globulin,gamma(IgG)stwk | VIAL | 10 % | N | Y | |
| 61476010410 | ALYGLO | immune globulin,gamma(IgG)stwk | VIAL | 10 % | N | Y | |
| 61476010420 | ALYGLO | immune globulin,gamma(IgG)stwk | VIAL | 10 % | N | Y | |
| 76125015002 | KEDRAB | rabies immune globulin/PF | VIAL | 150 unit/mL | Y | ||
| 76125015003 | KEDRAB | rabies immune globulin/PF | VIAL | 150 unit/mL | Y | ||
| 76125015010 | KEDRAB | rabies immune globulin/PF | VIAL | 150 unit/mL | Y | ||
| 76125015011 | KEDRAB | rabies immune globulin/PF | VIAL | 150 unit/mL | Y | ||
| 13533031801 | HYPERRAB | rabies immune globulin/PF | VIAL | 300 unit/mL | Y | ||
| 13533031803 | HYPERRAB | rabies immune globulin/PF | VIAL | 300 unit/mL | Y | ||
| 13533031805 | HYPERRAB | rabies immune globulin/PF | VIAL | 300 unit/mL | Y | ||
| 13533031810 | HYPERRAB | rabies immune globulin/PF | VIAL | 300 unit/mL | Y | ||
| 13533031830 | HYPERRAB | rabies immune globulin/PF | VIAL | 300 unit/mL | Y | ||
| 13533031850 | HYPERRAB | rabies immune globulin/PF | VIAL | 300 unit/mL | Y | ||
| 13533063102 | HYPERRHO S-D | Rho(D) immune globulin | SYRINGE | 1,500 unit (300 mcg) | Y | ||
| 13533063103 | HYPERRHO S-D | Rho(D) immune globulin | SYRINGE | 1,500 unit (300 mcg) | Y | ||
| 13533063111 | HYPERRHO S-D | Rho(D) immune globulin | SYRINGE | 1,500 unit (300 mcg) | Y | ||
| 13533063120 | HYPERRHO S-D | Rho(D) immune globulin | SYRINGE | 1,500 unit (300 mcg) | Y | ||
| 00562780500 | RHOGAM ULTRA-FILTERED PLUS | Rho(D) immune globulin | SYRINGE | 1,500 unit (300 mcg) | Y | ||
| 00562780501 | RHOGAM ULTRA-FILTERED PLUS | Rho(D) immune globulin | SYRINGE | 1,500 unit (300 mcg) | Y | ||
| 00562780505 | RHOGAM ULTRA-FILTERED PLUS | Rho(D) immune globulin | SYRINGE | 1,500 unit (300 mcg) | Y | ||
| 00562780525 | RHOGAM ULTRA-FILTERED PLUS | Rho(D) immune globulin | SYRINGE | 1,500 unit (300 mcg) | Y | ||
| 44206030001 | RHOPHYLAC | Rho(D) immune globulin | SYRINGE | 1,500 unit (300 mcg)/2 mL | Y | ||
| 44206030010 | RHOPHYLAC | Rho(D) immune globulin | SYRINGE | 1,500 unit (300 mcg)/2 mL | Y | ||
| 44206030090 | RHOPHYLAC | Rho(D) immune globulin | SYRINGE | 1,500 unit (300 mcg)/2 mL | Y | ||
| 13533066106 | HYPERRHO S-D | Rho(D) immune globulin | SYRINGE | 250 unit (50 mcg) | Y | ||
| 13533066160 | HYPERRHO S-D | Rho(D) immune globulin | SYRINGE | 250 unit (50 mcg) | Y | ||
| 49591033011 | WINRHO SDF | Rho(D) immune globulin/maltose | VIAL | 1,500 unit (300 mcg)/1.3 mL | Y | ||
| 49591033051 | WINRHO SDF | Rho(D) immune globulin/maltose | VIAL | 1,500 unit (300 mcg)/1.3 mL | Y | ||
| 49591030013 | WINRHO SDF | Rho(D) immune globulin/maltose | VIAL | 15,000 unit (3,000 mcg)/13 mL | Y | ||
| 49591030051 | WINRHO SDF | Rho(D) immune globulin/maltose | VIAL | 15,000 unit (3,000 mcg)/13 mL | Y | ||
| 49591035002 | WINRHO SDF | Rho(D) immune globulin/maltose | VIAL | 2,500 unit (500 mcg)/2.2 mL | Y | ||
| 49591035051 | WINRHO SDF | Rho(D) immune globulin/maltose | VIAL | 2,500 unit (500 mcg)/2.2 mL | Y | ||
| 70257031004 | WINRHO SDF | Rho(D) immune globulin/maltose | VIAL | 5,000 unit (1,000 mcg)/4.4 mL | Y | ||
| 70257031051 | WINRHO SDF | Rho(D) immune globulin/maltose | VIAL | 5,000 unit (1,000 mcg)/4.4 mL | Y | ||
| 13533063402 | HYPERTET | tetanus immune globulin/PF | SYRINGE | 250 unit/mL | Y | ||
| 13533063420 | HYPERTET | tetanus immune globulin/PF | SYRINGE | 250 unit/mL | Y | ||
| 42023010401 | APLISOL | tuberculin,purif.prot.deriv. | VIAL | 5 tub. unit/0.1 mL | Y | ||
| 42023010405 | APLISOL | tuberculin,purif.prot.deriv. | VIAL | 5 tub. unit/0.1 mL | Y | ||
| 49591012611 | VARIZIG | varicella-zoster Ig/maltose | VIAL | 125 unit/1.2 mL | Y | ||
| 49591012651 | VARIZIG | varicella-zoster Ig/maltose | VIAL | 125 unit/1.2 mL | Y |