Iron Chelators
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 |
|---|---|---|---|---|---|---|
| deferoxamine mesylate | DEFEROXAMINE MESYLATE | VIAL | Y | N | ||
| deferasirox | DEFERASIROX | GRAN PACK | N | N | ||
| deferasirox | DEFERASIROX | TAB DISPER | N | N | ||
| deferasirox | EXJADE | TAB DISPER | N | N | ||
| deferasirox | JADENU | TABLET | N | N | ||
| deferiprone | DEFERIPRONE | TABLET | N | N | ||
| deferiprone | FERRIPROX (2 TIMES A DAY) | TABLET MR | N | N |