Colony Stimulating Factors
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 | New Drug Evaluation |
|---|---|---|---|---|---|
| filgrastim | NEUPOGEN | SYRINGE | Y | ||
| filgrastim | NEUPOGEN | VIAL | Y | ||
| pegfilgrastim-apgf | NYVEPRIA | SYRINGE | 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-bmez | ZIEXTENZO | SYRINGE | N | ||
| pegfilgrastim-cbqv | UDENYCA AUTOINJECTOR | AUTO INJCT | 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 |