Multiple Sclerosis

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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.

Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria New Drug Evaluation
glatiramer acetate COPAXONE SYRINGE Y PA Document  
interferon beta-1a AVONEX PEN PEN IJ KIT Y    
interferon beta-1a AVONEX SYRINGE Y    
interferon beta-1a AVONEX SYRINGEKIT Y    
interferon beta-1a/albumin REBIF REBIDOSE PEN INJCTR Y    
interferon beta-1a/albumin REBIF SYRINGE Y    
interferon beta-1b BETASERON KIT Y    
peginterferon beta-1a PLEGRIDY PEN PEN INJCTR Y    
peginterferon beta-1a PLEGRIDY SYRINGE Y    
alemtuzumab LEMTRADA VIAL N PA Document  
cladribine MAVENCLAD TABLET N PA Document  
dalfampridine AMPYRA TAB ER 12H N PA Document Jul 25, 2013
dalfampridine DALFAMPRIDINE ER TAB ER 12H N PA Document  
dimethyl fumarate TECFIDERA CAPSULE DR N PA Document  
dimethyl fumarate DIMETHYL FUMARATE CAPSULE DR N PA Document  
diroximel fumarate VUMERITY CAPSULE DR N PA Document  
fingolimod HCl FINGOLIMOD CAPSULE N PA Document  
fingolimod HCl GILENYA CAPSULE N PA Document  
fingolimod lauryl sulfate TASCENSO ODT TAB RAPDIS N PA Document  
glatiramer acetate COPAXONE SYRINGE N PA Document  
glatiramer acetate GLATIRAMER ACETATE SYRINGE N PA Document  
glatiramer acetate GLATOPA SYRINGE N PA Document  
interferon beta-1b BETASERON VIAL N PA Document  
monomethyl fumarate BAFIERTAM CAPSULE DR N PA Document  
ocrelizumab OCREVUS VIAL N PA Document  
ofatumumab KESIMPTA PEN PEN INJCTR N PA Document  
ozanimod hydrochloride ZEPOSIA CAP DS PK N PA Document  
ozanimod hydrochloride ZEPOSIA CAPSULE N PA Document  
ponesimod PONVORY TAB DS PK N PA Document  
ponesimod PONVORY TABLET N PA Document  
siponimod MAYZENT TAB DS PK N PA Document  
siponimod MAYZENT TABLET N PA Document  
teriflunomide TERIFLUNOMIDE TABLET N PA Document  
teriflunomide AUBAGIO TABLET N PA Document May 30, 2013
ublituximab-xiiy BRIUMVI VIAL N PA Document  
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