Cystic Fibrosis

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Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria Carveout
‐ Bill FFS
New Drug Evaluation & Updates
dornase alfa PULMOZYME SOLUTION Y    
sodium chloride for inhalation SODIUM CHLORIDE VIAL-NEB Y    
sodium chloride for inhalation SODIUM CHLORIDE VIAL-NEB Y    
tobramycin in 0.225% sod chlor TOBRAMYCIN AMPUL-NEB Y    
tobramycin in 0.225% sod chlor TOBI AMPUL-NEB Y    
amikacin liposomal/neb.accessr ARIKAYCE VIAL-NEB N Pharmacy PA Nov 21, 2019
aztreonam lysine CAYSTON VIAL-NEB N    
elexacaftor/tezacaftor/ivacaft TRIKAFTA GRAN PK SQ N Pharmacy PA  
elexacaftor/tezacaftor/ivacaft TRIKAFTA TABLET SEQ N Pharmacy PA  
ivacaftor KALYDECO GRAN PACK N Pharmacy PA  
ivacaftor KALYDECO TABLET N Pharmacy PA Jun 28, 2012
May 28, 2015
lumacaftor/ivacaftor ORKAMBI GRAN PACK N Pharmacy PA  
lumacaftor/ivacaftor ORKAMBI TABLET N Pharmacy PA Nov 19, 2015
tezacaftor/ivacaftor SYMDEKO TABLET SEQ N Pharmacy PA  
tobramycin TOBRAMYCIN AMPUL-NEB N    
tobramycin BETHKIS AMPUL-NEB N    
tobramycin TOBI PODHALER CAP W/DEV N    
tobramycin/nebulizer TOBRAMYCIN AMPUL-NEB N    
tobramycin/nebulizer KITABIS PAK AMPUL-NEB N    
vanzacaftor/tezacaf/deutivacaf ALYFTREK TABLET N Pharmacy PA