Physician Administered Drugs

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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 but eligible patients will encounter a co-pay at the pharmacy.
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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
adalimumab HUMIRA(CF) PEN PSOR-UV-ADOL HS PEN IJ KIT Y PA Document  
adalimumab HUMIRA(CF) PEN PEN IJ KIT Y PA Document  
adalimumab HUMIRA PEN PSOR-UVEITS-ADOL HS PEN IJ KIT Y PA Document  
adalimumab HUMIRA PEN CROHN'S-UC-HS PEN IJ KIT Y PA Document  
adalimumab HUMIRA PEN PEN IJ KIT Y PA Document  
adalimumab HUMIRA(CF) PEN CROHN'S-UC-HS PEN IJ KIT Y PA Document  
adalimumab HUMIRA(CF) SYRINGEKIT Y PA Document  
adalimumab HUMIRA PEDIATRIC CROHN'S SYRINGEKIT Y PA Document  
adalimumab HUMIRA SYRINGEKIT Y PA Document  
adalimumab HUMIRA(CF) PEDIATRIC CROHN'S SYRINGEKIT Y PA Document  
etanercept ENBREL MINI CARTRIDGE Y PA Document  
etanercept ENBREL SURECLICK PEN INJCTR Y PA Document  
etanercept ENBREL SYRINGE Y PA Document  
etanercept ENBREL VIAL Y PA Document  
hydroxyprogesterone caproat/PF MAKENA AUTO INJCT Y PA Document  
hydroxyprogesterone caproat/PF MAKENA VIAL Y PA Document  
hydroxyprogesterone caproate MAKENA VIAL Y PA Document May 30, 2013
abatacept ORENCIA CLICKJECT AUTO INJCT N PA Document  
abatacept ORENCIA SYRINGE N PA Document  
abatacept/maltose ORENCIA VIAL N PA Document  
anakinra KINERET SYRINGE N PA Document  
apremilast OTEZLA TAB DS PK N PA Document  
apremilast OTEZLA TABLET N PA Document  
baricitinib OLUMIANT TABLET N PA Document  
belimumab BENLYSTA AUTO INJCT N PA Document May 24, 2018
belimumab BENLYSTA SYRINGE N PA Document May 24, 2018
belimumab BENLYSTA VIAL N PA Document May 24, 2018
brodalumab SILIQ SYRINGE N PA Document  
canakinumab/PF ILARIS VIAL N PA Document  
certolizumab pegol CIMZIA KIT N PA Document  
certolizumab pegol CIMZIA SYRINGEKIT N PA Document  
golimumab SIMPONI PEN INJCTR N PA Document  
golimumab SIMPONI SYRINGE N PA Document  
golimumab SIMPONI ARIA VIAL N PA Document  
guselkumab TREMFYA AUTO INJCT N PA Document  
guselkumab TREMFYA SYRINGE N PA Document  
hydroxyprogesterone caproat/PF HYDROXYPROGESTERONE CAPROATE VIAL N PA Document  
hydroxyprogesterone caproate HYDROXYPROGESTERONE CAPROATE VIAL N PA Document  
incobotulinumtoxinA XEOMIN VIAL N PA Document  
infliximab REMICADE VIAL N PA Document  
infliximab-abda RENFLEXIS VIAL N PA Document  
infliximab-dyyb INFLECTRA VIAL N PA Document  
ixekizumab TALTZ AUTOINJECTOR (3 PACK) AUTO INJCT N PA Document Nov 17, 2016
ixekizumab TALTZ AUTOINJECTOR (2 PACK) AUTO INJCT N PA Document Nov 17, 2016
ixekizumab TALTZ AUTOINJECTOR AUTO INJCT N PA Document Nov 17, 2016
ixekizumab TALTZ SYRINGE SYRINGE N PA Document Nov 17, 2016
natalizumab TYSABRI VIAL N PA Document  
ocrelizumab OCREVUS VIAL N PA Document  
rituximab RITUXAN VIAL N PA Document  
sarilumab KEVZARA PEN INJCTR N PA Document  
sarilumab KEVZARA SYRINGE N PA Document  
secukinumab COSENTYX PEN (2 PENS) PEN INJCTR N PA Document Jul 30, 2015
secukinumab COSENTYX PEN PEN INJCTR N PA Document Jul 30, 2015
secukinumab COSENTYX SYRINGE SYRINGE N PA Document Jul 30, 2015
secukinumab COSENTYX (2 SYRINGES) SYRINGE N PA Document Jul 30, 2015
tocilizumab ACTEMRA ACTPEN PEN INJCTR N PA Document  
tocilizumab ACTEMRA SYRINGE N PA Document  
tocilizumab ACTEMRA VIAL N PA Document  
tofacitinib citrate XELJANZ XR TAB ER 24H N PA Document  
tofacitinib citrate XELJANZ TABLET N PA Document  
ustekinumab STELARA SYRINGE N PA Document  
ustekinumab STELARA VIAL N PA Document  
vedolizumab ENTYVIO VIAL N PA Document  
abobotulinumtoxinA DYSPORT VIAL PA Document  
edaravone RADICAVA PIGGYBACK PA Document Jul 26, 2018
eteplirsen EXONDYS 51 VIAL PA Document Jul 27, 2017
incobotulinumtoxinA XEOMIN VIAL PA Document  
nusinersen sodium/PF SPINRAZA VIAL PA Document Jul 27, 2017
onabotulinumtoxinA BOTOX VIAL PA Document  
onabotulinumtoxinA BOTOX COSMETIC VIAL PA Document  
rimabotulinumtoxinB MYOBLOC VIAL PA Document  
voretigene neparvovec-rzyl LUXTURNA VIAL PA Document Mar 22, 2018