Colony Stimulating Factors

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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
Current Drug Use Criteria New Drug Evaluation
filgrastim NEUPOGEN SYRINGE Y    
filgrastim NEUPOGEN VIAL Y    
sargramostim LEUKINE VIAL Y    
eflapegrastim-xnst ROLVEDON SYRINGE N    
filgrastim-aafi NIVESTYM SYRINGE N    
filgrastim-aafi NIVESTYM VIAL N    
filgrastim-ayow RELEUKO SYRINGE N    
filgrastim-ayow RELEUKO VIAL N    
filgrastim-sndz ZARXIO SYRINGE N    
pegfilgrastim NEULASTA ONPRO SYR W/ INJ N    
pegfilgrastim NEULASTA SYRINGE N    
pegfilgrastim-apgf NYVEPRIA SYRINGE N    
pegfilgrastim-bmez ZIEXTENZO SYRINGE N    
pegfilgrastim-cbqv UDENYCA ONBODY SYR W/ INJ N    
pegfilgrastim-cbqv UDENYCA SYRINGE N    
pegfilgrastim-fpgk STIMUFEND SYRINGE N    
pegfilgrastim-jmdb FULPHILA SYRINGE N    
pegfilgrastim-pbbk FYLNETRA SYRINGE N    
tbo-filgrastim GRANIX SYRINGE N    
tbo-filgrastim GRANIX VIAL N