Erythropoiesis Stimulating Agents
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 |
---|---|---|---|---|---|
darbepoetin alfa in polysorbat | ARANESP | SYRINGE | Y | ||
darbepoetin alfa in polysorbat | ARANESP | VIAL | Y | ||
epoetin alfa | PROCRIT | VIAL | N | ||
epoetin alfa | EPOGEN | VIAL | N | ||
epoetin alfa-epbx | RETACRIT | VIAL | N | ||
methoxy peg-epoetin beta | MIRCERA | SYRINGE | N |