Multiple Sclerosis

← Back to Class List

PDL Reference Documents

Drug Use Review 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.

Alternate detailed view >

Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
interferon beta-1a AVONEX SYRINGE Y   N  
interferon beta-1a/albumin REBIF SYRINGE Y   N  
interferon beta-1b BETASERON KIT Y   N  
cladribine MAVENCLAD TABLET N Pharmacy PA N  
dalfampridine DALFAMPRIDINE ER TAB ER 12H N Pharmacy PA N  
dimethyl fumarate TECFIDERA CAPSULE DR N Pharmacy PA N  
diroximel fumarate VUMERITY CAPSULE DR N Pharmacy PA N  
fingolimod HCl FINGOLIMOD CAPSULE N Pharmacy PA N  
fingolimod lauryl sulfate TASCENSO ODT TAB RAPDIS N Pharmacy PA N  
glatiramer acetate COPAXONE SYRINGE N Pharmacy PA N  
glatiramer acetate GLATIRAMER ACETATE SYRINGE N Pharmacy PA N  
monomethyl fumarate BAFIERTAM CAPSULE DR N Pharmacy PA N  
natalizumab-sztn TYRUKO VIAL N   N  
ocrelizumab OCREVUS VIAL N Pharmacy PA N  
ozanimod hydrochloride ZEPOSIA CAP DS PK N Pharmacy PA N  
ponesimod PONVORY TAB DS PK N Pharmacy PA N  
siponimod MAYZENT TAB DS PK N Pharmacy PA N  
teriflunomide TERIFLUNOMIDE TABLET N Pharmacy PA N  
ublituximab-xiiy BRIUMVI VIAL N Pharmacy PA N  
Back to Top ↑