Targeted Immune Modulators
PDL Reference Documents
Drug Use Review Documents
Newsletters
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 |
|---|---|---|---|---|---|---|
| adalimumab | HUMIRA(CF) PEN PSOR-UV-ADOL HS | PEN IJ KIT | Y | Pharmacy PA | N | |
| adalimumab | HUMIRA(CF) PEN CROHN'S-UC-HS | PEN IJ KIT | Y | Pharmacy PA | N | |
| adalimumab | HUMIRA(CF) PEN | PEN IJ KIT | Y | Pharmacy PA | N | |
| adalimumab | HUMIRA PEN | PEN IJ KIT | Y | Pharmacy PA | N | |
| adalimumab | HUMIRA(CF) | SYRINGEKIT | Y | Pharmacy PA | N | |
| adalimumab | HUMIRA | SYRINGEKIT | Y | Pharmacy PA | N | |
| adalimumab-atto | AMJEVITA(CF) AUTOINJECTOR | AUTO INJCT | Y | Pharmacy PA | N | |
| adalimumab-atto | AMJEVITA(CF) | SYRINGE | Y | Pharmacy PA | N | |
| adalimumab-fkjp | ADALIMUMAB-FKJP(CF) PEN | PEN IJ KIT | Y | Pharmacy PA | N | |
| adalimumab-fkjp | ADALIMUMAB-FKJP(CF) PEN | PEN INJCTR | Y | Pharmacy PA | N | |
| adalimumab-fkjp | ADALIMUMAB-FKJP(CF) | SYRINGE | Y | Pharmacy PA | N | |
| adalimumab-fkjp | ADALIMUMAB-FKJP(CF) | SYRINGEKIT | Y | Pharmacy PA | N | |
| adalimumab-ryvk | SIMLANDI(CF) AUTOINJECTOR | AUTOINJKIT | Y | Pharmacy PA | N | |
| adalimumab-ryvk | SIMLANDI(CF) | SYRINGEKIT | Y | Pharmacy PA | N | |
| apremilast | OTEZLA | TAB DS PK | Y | Pharmacy PA | N | |
| apremilast | OTEZLA | TABLET | Y | Pharmacy PA | N | |
| etanercept | ENBREL MINI | CARTRIDGE | Y | Pharmacy PA | N | |
| etanercept | ENBREL SURECLICK | PEN INJCTR | Y | Pharmacy PA | N | |
| etanercept | ENBREL | SYRINGE | Y | Pharmacy PA | N | |
| etanercept | ENBREL | VIAL | Y | Pharmacy PA | N | |
| infliximab-axxq | AVSOLA | VIAL | Y | Pharmacy PA | N | |
| ixekizumab | TALTZ AUTOINJECTOR | AUTO INJCT | Y | Pharmacy PA | N | Nov 17, 2016 |
| ixekizumab | TALTZ AUTOINJECTOR (2 PACK) | AUTO INJCT | Y | Pharmacy PA | N | Nov 17, 2016 |
| ixekizumab | TALTZ AUTOINJECTOR (3 PACK) | AUTO INJCT | Y | Pharmacy PA | N | Nov 17, 2016 |
| ixekizumab | TALTZ SYRINGE | SYRINGE | Y | Pharmacy PA | N | Nov 17, 2016 |
| tofacitinib citrate | XELJANZ | SOLUTION | Y | Pharmacy PA | N | |
| tofacitinib citrate | XELJANZ XR | TAB ER 24H | Y | Pharmacy PA | N | |
| tofacitinib citrate | XELJANZ | TABLET | Y | Pharmacy PA | N | |
| abatacept | ORENCIA CLICKJECT | AUTO INJCT | N | Pharmacy PA | N | |
| abatacept | ORENCIA | SYRINGE | N | Pharmacy PA | N | |
| abatacept/maltose | ORENCIA | VIAL | N | Pharmacy PA | N | |
| adalimumab-aacf | ADALIMUMAB-AACF(CF) PEN PS-UV | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-aacf | IDACIO(CF) PEN CROHN'S-UC(6PK) | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-aacf | IDACIO(CF) PEN PSORIASIS (4PK) | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-aacf | ADALIMUMAB-AACF(CF) PEN CROHNS | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-aacf | ADALIMUMAB-AACF(CF) PEN (2 PK) | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-aacf | IDACIO(CF) PEN | PEN INJCTR | N | Pharmacy PA | N | |
| adalimumab-aacf | ADALIMUMAB-AACF(CF) | SYRINGE | N | Pharmacy PA | N | |
| adalimumab-aacf | ADALIMUMAB-AACF(CF) (2 PK) | SYRINGEKIT | N | Pharmacy PA | N | |
| adalimumab-aaty | YUFLYMA(CF) AUTOINJECTOR | AUTOINJKIT | N | Pharmacy PA | N | |
| adalimumab-aaty | ADALIMUMAB-AATY(CF) AI CROHNS | AUTOINJKIT | N | Pharmacy PA | N | |
| adalimumab-aaty | ADALIMUMAB-AATY(CF) AUTOINJECT | AUTOINJKIT | N | Pharmacy PA | N | |
| adalimumab-aaty | YUFLYMA(CF) AI CROHN'S-UC-HS | AUTOINJKIT | N | Pharmacy PA | N | |
| adalimumab-aaty | ADALIMUMAB-AATY(CF) | SYRINGEKIT | N | Pharmacy PA | N | |
| adalimumab-aaty | YUFLYMA(CF) | SYRINGEKIT | N | Pharmacy PA | N | |
| adalimumab-adaz | ADALIMUMAB-ADAZ(CF) PEN | PEN INJCTR | N | Pharmacy PA | N | |
| adalimumab-adaz | HYRIMOZ(CF) PEN | PEN INJCTR | N | Pharmacy PA | N | |
| adalimumab-adaz | HYRIMOZ(CF) PEN CROHN-UC START | PEN INJCTR | N | Pharmacy PA | N | |
| adalimumab-adaz | HYRIMOZ(CF) PEN PSORIASIS | PEN INJCTR | N | Pharmacy PA | N | |
| adalimumab-adaz | ADALIMUMAB-ADAZ(CF) | SYRINGE | N | Pharmacy PA | N | |
| adalimumab-adaz | HYRIMOZ(CF) PEDIATRIC CROHN'S | SYRINGE | N | Pharmacy PA | N | |
| adalimumab-adaz | HYRIMOZ(CF) | SYRINGE | N | Pharmacy PA | N | |
| adalimumab-adbm | CYLTEZO(CF) PEN | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-adbm | ADALIMUMAB-ADBM(CF) PEN | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-adbm | CYLTEZO(CF) PEN CROHN'S-UC-HS | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-adbm | CYLTEZO(CF) PEN PSORIASIS-UV | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-adbm | ADALIMUMAB-ADBM(CF)PEN | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-adbm | ADALIMUMAB-ADBM(CF) | SYRINGEKIT | N | Pharmacy PA | N | |
| adalimumab-adbm | CYLTEZO(CF) | SYRINGEKIT | N | Pharmacy PA | N | |
| adalimumab-afzb | ABRILADA(CF) PEN | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-afzb | ABRILADA(CF) PEN (2 PACK) | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-afzb | ABRILADA(CF) | SYRINGEKIT | N | Pharmacy PA | N | |
| adalimumab-aqvh | YUSIMRY(CF) PEN | PEN INJCTR | N | Pharmacy PA | N | |
| adalimumab-atto | AMJEVITA(CF) AUTOINJECTOR | AUTO INJCT | N | Pharmacy PA | N | |
| adalimumab-atto | AMJEVITA(CF) | SYRINGE | N | Pharmacy PA | N | |
| adalimumab-bwwd | HADLIMA PUSHTOUCH | AUTO INJCT | N | Pharmacy PA | N | |
| adalimumab-bwwd | HADLIMA(CF) PUSHTOUCH | AUTO INJCT | N | Pharmacy PA | N | |
| adalimumab-bwwd | HADLIMA | SYRINGE | N | Pharmacy PA | N | |
| adalimumab-bwwd | HADLIMA(CF) | SYRINGE | N | Pharmacy PA | N | |
| adalimumab-fkjp | HULIO(CF) PEN | PEN IJ KIT | N | Pharmacy PA | N | |
| adalimumab-fkjp | HULIO(CF) PEN | PEN INJCTR | N | Pharmacy PA | N | |
| adalimumab-fkjp | HULIO(CF) | SYRINGE | N | Pharmacy PA | N | |
| adalimumab-fkjp | HULIO(CF) | SYRINGEKIT | N | Pharmacy PA | N | |
| adalimumab-ryvk | ADALIMUMAB-RYVK(CF) AUTOINJECT | AUTOINJKIT | N | Pharmacy PA | N | |
| adalimumab-ryvk | ADALIMUMAB-RYVK(CF) | SYRINGEKIT | N | Pharmacy PA | N | |
| anakinra | KINERET | SYRINGE | N | Pharmacy PA | N | |
| apremilast | OTEZLA XR | TAB ER 24H | N | Pharmacy PA | N | |
| apremilast | OTEZLA XR | TB TBER DP | N | Pharmacy PA | N | |
| baricitinib | OLUMIANT | TABLET | N | Pharmacy PA | N | |
| bimekizumab-bkzx | BIMZELX AUTOINJECTOR | AUTO INJCT | N | Pharmacy PA | N | |
| bimekizumab-bkzx | BIMZELX | SYRINGE | N | Pharmacy PA | N | |
| canakinumab/PF | ILARIS | VIAL | N | Pharmacy PA | N | |
| certolizumab pegol | CIMZIA (2 PACK) | KIT | N | Pharmacy PA | N | |
| certolizumab pegol | CIMZIA | SYRINGEKIT | N | Pharmacy PA | N | |
| certolizumab pegol | CIMZIA (2 PACK) | SYRINGEKIT | N | Pharmacy PA | N | |
| deucravacitinib | SOTYKTU | TABLET | N | Pharmacy PA | N | |
| etrasimod arginine | VELSIPITY | TABLET | N | Pharmacy PA | N | |
| golimumab | SIMPONI | PEN INJCTR | N | Pharmacy PA | N | |
| golimumab | SIMPONI | SYRINGE | N | Pharmacy PA | N | |
| golimumab | SIMPONI ARIA | VIAL | N | Pharmacy PA | N | |
| guselkumab | TREMFYA ONE-PRESS | AUTO INJCT | N | Pharmacy PA | N | |
| guselkumab | TREMFYA PEN | PEN INJCTR | N | Pharmacy PA | N | |
| guselkumab | TREMFYA PEN INDUCTION (2 PEN) | PEN INJCTR | N | Pharmacy PA | N | |
| guselkumab | TREMFYA | SYRINGE | N | Pharmacy PA | N | |
| guselkumab | TREMFYA | VIAL | N | Pharmacy PA | N | |
| infliximab | INFLIXIMAB | VIAL | N | Pharmacy PA | N | |
| infliximab | REMICADE | VIAL | N | Pharmacy PA | N | |
| infliximab-abda | RENFLEXIS | VIAL | N | Pharmacy PA | N | |
| infliximab-dyyb | ZYMFENTRA PEN | PEN IJ KIT | N | Pharmacy PA | N | |
| infliximab-dyyb | ZYMFENTRA | SYRINGEKIT | N | Pharmacy PA | N | |
| infliximab-dyyb | INFLECTRA | VIAL | N | Pharmacy PA | N | |
| mirikizumab-mrkz | OMVOH PEN | PEN INJCTR | N | Pharmacy PA | N | |
| mirikizumab-mrkz | OMVOH | SYRINGE | N | Pharmacy PA | N | |
| mirikizumab-mrkz | OMVOH | VIAL | N | Pharmacy PA | N | |
| natalizumab | TYSABRI | VIAL | N | Pharmacy PA | N | |
| natalizumab-sztn | TYRUKO | VIAL | N | Pharmacy PA | N | |
| risankizumab-rzaa | SKYRIZI PEN | PEN INJCTR | N | Pharmacy PA | N | |
| risankizumab-rzaa | SKYRIZI | SYRINGE | N | Pharmacy PA | N | |
| risankizumab-rzaa | SKYRIZI | VIAL | N | Pharmacy PA | N | |
| risankizumab-rzaa | SKYRIZI ON-BODY | WEAR INJCT | N | Pharmacy PA | N | |
| rituximab | RITUXAN | VIAL | N | Pharmacy PA | N | |
| rituximab-abbs | TRUXIMA | VIAL | N | Pharmacy PA | N | |
| rituximab-arrx | RIABNI | VIAL | N | Pharmacy PA | N | |
| rituximab-pvvr | RUXIENCE | VIAL | N | Pharmacy PA | N | |
| sarilumab | KEVZARA | PEN INJCTR | N | Pharmacy PA | N | |
| sarilumab | KEVZARA | SYRINGE | N | Pharmacy PA | N | |
| secukinumab | COSENTYX UNOREADY PEN | PEN INJCTR | N | Pharmacy PA | N | Jul 30, 2015 |
| secukinumab | COSENTYX SENSOREADY (2 PENS) | PEN INJCTR | N | Pharmacy PA | N | Jul 30, 2015 |
| secukinumab | COSENTYX SENSOREADY PEN | PEN INJCTR | N | Pharmacy PA | N | Jul 30, 2015 |
| secukinumab | COSENTYX (2 SYRINGES) | SYRINGE | N | Pharmacy PA | N | Jul 30, 2015 |
| secukinumab | COSENTYX SYRINGE | SYRINGE | N | Pharmacy PA | N | Jul 30, 2015 |
| secukinumab | COSENTYX | VIAL | N | Pharmacy PA | N | Jul 30, 2015 |
| spesolimab-sbzo | SPEVIGO | SYRINGE | N | Pharmacy PA | N | |
| spesolimab-sbzo | SPEVIGO | VIAL | N | Pharmacy PA | N | |
| tildrakizumab-asmn | ILUMYA | SYRINGE | N | Pharmacy PA | N | |
| tocilizumab | ACTEMRA ACTPEN | PEN INJCTR | N | Pharmacy PA | N | |
| tocilizumab | ACTEMRA | SYRINGE | N | Pharmacy PA | N | |
| tocilizumab | ACTEMRA | VIAL | N | Pharmacy PA | N | |
| tocilizumab-aazg | TYENNE AUTOINJECTOR | PEN INJCTR | N | Pharmacy PA | N | |
| tocilizumab-aazg | TYENNE | SYRINGE | N | Pharmacy PA | N | |
| tocilizumab-aazg | TYENNE | VIAL | N | Pharmacy PA | N | |
| tocilizumab-anoh | AVTOZMA | VIAL | N | Pharmacy PA | N | |
| tocilizumab-bavi | TOFIDENCE | VIAL | N | Pharmacy PA | N | |
| upadacitinib | RINVOQ LQ | SOLUTION | N | Pharmacy PA | N | |
| upadacitinib | RINVOQ | TAB ER 24H | N | Pharmacy PA | N | |
| ustekinumab | STELARA | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab | USTEKINUMAB | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab | STELARA | VIAL | N | Pharmacy PA | N | |
| ustekinumab | USTEKINUMAB | VIAL | N | Pharmacy PA | N | |
| ustekinumab-aauz | OTULFI | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab-aauz | USTEKINUMAB-AAUZ | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab-aauz | OTULFI | VIAL | N | Pharmacy PA | N | |
| ustekinumab-aekn | USTEKINUMAB-AEKN | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab-aekn | SELARSDI | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab-aekn | SELARSDI | VIAL | N | Pharmacy PA | N | |
| ustekinumab-hmny | STARJEMZA | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab-hmny | STARJEMZA | VIAL | N | Pharmacy PA | N | |
| ustekinumab-kfce | YESINTEK | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab-kfce | YESINTEK | VIAL | N | Pharmacy PA | N | |
| ustekinumab-srlf | IMULDOSA | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab-srlf | IMULDOSA | VIAL | N | Pharmacy PA | N | |
| ustekinumab-stba | STEQEYMA | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab-stba | STEQEYMA | VIAL | N | Pharmacy PA | N | |
| ustekinumab-ttwe | PYZCHIVA | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab-ttwe | USTEKINUMAB-TTWE | SYRINGE | N | Pharmacy PA | N | |
| ustekinumab-ttwe | PYZCHIVA | VIAL | N | Pharmacy PA | N | |
| ustekinumab-ttwe | USTEKINUMAB-TTWE | VIAL | N | Pharmacy PA | N | |
| vedolizumab | ENTYVIO PEN | PEN INJCTR | N | Pharmacy PA | N | |
| vedolizumab | ENTYVIO | VIAL | N | Pharmacy PA | N | |
| mirikizumab-mrkz | OMVOH PEN | PEN INJCTR | Pharmacy PA | N | ||
| mirikizumab-mrkz | OMVOH | SYRINGE | Pharmacy PA | N | ||
| ustekinumab-aekn | USTEKINUMAB-AEKN | SYRINGE | Pharmacy PA | N |