Cystic Fibrosis
PDL Reference Documents
- Inhaled Drugs for Cystic Fibrosis - Dec 02, 2021
- Cystic Fibrosis - Jun 03, 2021
- Cystic Fibrosis Class Update - Jun 04, 2020
- Cystic Fibrosis - Sep 26, 2019
- Oral Cystic Fibrosis Modulators - Sep 27, 2018
- Oral Cystic Fibrosis Modulators - Jul 26, 2018
- Oral Cystic Fibrosis Modulators - Nov 17, 2016
- Inhaled Drugs for Cystic Fibrosis - Jan 28, 2016
- Inhaled Medications for Cystic Fibrosis - May 28, 2015
- Cystic Fibrosis Abbreviated Class Update - May 29, 2014
- Cystic Fibrosis - Inhaled Antibiotics Class Update - Mar 27, 2014
- Abbreviated Class Review: Fat-Soluble Vitamins for the Use of Cystic Fybrosis - May 30, 2013
- Abbreviated Drug Evaluation: Hypertonic Saline Inhalation for Cystic Fybrosis - Sep 27, 2012
- Abbreviated Class Review: Inhaled Antibiotics and Dornase Alfa for Cystic Fibrosis - Aug 30, 2012
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 & 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 | TOBI | AMPUL-NEB | Y | ||
tobramycin in 0.225% sod chlor | TOBRAMYCIN | AMPUL-NEB | Y | ||
amikacin liposomal/neb.accessr | ARIKAYCE | VIAL-NEB | N | PA Document | Nov 21, 2019 |
aztreonam lysine | CAYSTON | VIAL-NEB | N | ||
elexacaftor/tezacaftor/ivacaft | TRIKAFTA | GRAN PK SQ | N | PA Document | |
elexacaftor/tezacaftor/ivacaft | TRIKAFTA | TABLET SEQ | N | PA Document | |
ivacaftor | KALYDECO | GRAN PACK | N | PA Document | |
ivacaftor | KALYDECO | TABLET | N | PA Document | Jun 28, 2012 May 28, 2015 |
lumacaftor/ivacaftor | ORKAMBI | GRAN PACK | N | PA Document | |
lumacaftor/ivacaftor | ORKAMBI | TABLET | N | PA Document | Nov 19, 2015 |
mannitol | BRONCHITOL | CAP W/DEV | N | ||
tezacaftor/ivacaftor | SYMDEKO | TABLET SEQ | N | PA Document | |
tobramycin | BETHKIS | AMPUL-NEB | N | ||
tobramycin | TOBRAMYCIN | AMPUL-NEB | N | ||
tobramycin | TOBI PODHALER | CAP W/DEV | N | ||
tobramycin/nebulizer | KITABIS PAK | AMPUL-NEB | N | ||
tobramycin/nebulizer | TOBRAMYCIN | AMPUL-NEB | N | ||
vanzacaftor/tezacaf/deutivacaf | ALYFTREK | TABLET | N | PA Document |