Vascular Endothelial Growth Factors

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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
Current Drug Use Criteria New Drug Evaluation
bevacizumab AVASTIN VIAL Y    
aflibercept EYLEA SYRINGE N PA Document  
aflibercept EYLEA HD VIAL N PA Document  
aflibercept EYLEA VIAL N PA Document  
brolucizumab-dbll BEOVU SYRINGE N PA Document  
faricimab-svoa VABYSMO VIAL N PA Document  
ranibizumab LUCENTIS SYRINGE N PA Document  
ranibizumab SUSVIMO VIAL N PA Document  
ranibizumab LUCENTIS VIAL N PA Document  
ranibizumab-eqrn CIMERLI VIAL N PA Document  
ranibizumab-nuna BYOOVIZ VIAL N PA Document  
ranibizumab/init fill needle SUSVIMO VIAL N PA Document