Cystic Fibrosis

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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
Current Drug Use Criteria New Drug Evaluation
dornase alfa PULMOZYME SOLUTION Y    
sodium chloride for inhalation SODIUM CHLORIDE VIAL-NEB Y    
sodium chloride for inhalation SODIUM CHLORIDE VIAL-NEB Y    
tobramycin/nebulizer TOBRAMYCIN AMPUL-NEB Y    
tobramycin/nebulizer KITABIS PAK AMPUL-NEB Y    
aztreonam lysine CAYSTON VIAL-NEB N    
ivacaftor KALYDECO GRAN PACK N PA Document  
ivacaftor KALYDECO TABLET N PA Document Jun 28, 2012
lumacaftor/ivacaftor ORKAMBI GRAN PACK N PA Document  
lumacaftor/ivacaftor ORKAMBI TABLET N PA Document Nov 19, 2015
tezacaftor/ivacaftor SYMDEKO TABLET SEQ N PA Document  
tobramycin BETHKIS AMPUL-NEB N    
tobramycin TOBI PODHALER CAP W/DEV N    
tobramycin in 0.225% sod chlor TOBRAMYCIN AMPUL-NEB N    
tobramycin in 0.225% sod chlor TOBI AMPUL-NEB N    
amikacin liposomal/neb.accessr ARIKAYCE VIAL-NEB    
ivacaftor KALYDECO GRAN PACK PA Document