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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
hymenoptera allergenic extract VENOMIL MAINTENANCE VIAL    
hymenoptera allergenic extract VENOMIL INDIVIDUAL DIAGNOSTIC VIAL    
hymenoptera allergenic extract ALBAY VIAL    
mold extracts DERMATOPHYTIN O ALLERGEN    
pollen extracts POLLEN EXTRACT, GLYCERINATED ALLERGEN    
pollen extracts POLLEN EXTRACT, NON-GLYCER ALLERGEN