Iron Chelators

← Back to Class List

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
deferoxamine mesylate DESFERAL MESYLATE VIAL Y    
deferoxamine mesylate DEFEROXAMINE MESYLATE VIAL Y    
deferasirox DEFERASIROX GRAN PACK N    
deferasirox JADENU SPRINKLE GRAN PACK N    
deferasirox EXJADE TAB DISPER N    
deferasirox DEFERASIROX TAB DISPER N    
deferasirox DEFERASIROX TABLET N    
deferasirox JADENU TABLET N    
deferiprone FERRIPROX SOLUTION N    
deferiprone FERRIPROX TABLET N    
deferiprone FERRIPROX (2 TIMES A DAY) TABLET N    
deferiprone FERRIPROX (3 TIMES A DAY) TABLET N    
deferiprone DEFERIPRONE TABLET N    
deferiprone DEFERIPRONE (3 TIMES A DAY) TABLET N