Lysosomal Storage Disorders

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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
agalsidase beta FABRAZYME VIAL    
alglucosidase alfa LUMIZYME VIAL    
cerliponase alfa BRINEURA KIT    
cerliponase alfa BRINEURA VIAL    
eliglustat tartrate CERDELGA CAPSULE    
elosulfase alfa VIMIZIM VIAL    
galsulfase NAGLAZYME VIAL    
idursulfase ELAPRASE VIAL    
imiglucerase CEREZYME VIAL    
laronidase ALDURAZYME VIAL    
migalastat HCl GALAFOLD CAPSULE    
miglustat MIGLUSTAT CAPSULE    
miglustat ZAVESCA CAPSULE    
sebelipase alfa KANUMA VIAL    
taliglucerase alfa ELELYSO VIAL    
velaglucerase alfa VPRIV VIAL    
vestronidase alfa-vjbk MEPSEVII VIAL