Cystic Fibrosis
PDL Reference Documents
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| dornase alfa | PULMOZYME | SOLUTION | Y | N | ||
| tobramycin in 0.225% sod chlor | TOBI | AMPUL-NEB | Y | N | ||
| amikacin liposomal/neb.accessr | ARIKAYCE | VIAL-NEB | N | Pharmacy PA | N | Nov 21, 2019 |
| elexacaftor/tezacaftor/ivacaft | TRIKAFTA | GRAN PK SQ | N | Pharmacy PA | N | |
| elexacaftor/tezacaftor/ivacaft | TRIKAFTA | TABLET SEQ | N | Pharmacy PA | N | |
| ivacaftor | KALYDECO | TABLET | N | Pharmacy PA | N | Jun 28, 2012 May 28, 2015 |
| lumacaftor/ivacaftor | ORKAMBI | TABLET | N | Pharmacy PA | N | Nov 19, 2015 |
| tezacaftor/ivacaftor | SYMDEKO | TABLET SEQ | N | Pharmacy PA | N | |
| tobramycin/nebulizer | KITABIS PAK | AMPUL-NEB | N | N | ||
| vanzacaftor/tezacaf/deutivacaf | ALYFTREK | TABLET | N | Pharmacy PA | N |