Targeted Immune Modulators
PDL Reference Documents
- Targeted Immune Modulators DERP Summary - Aug 01, 2024
- Severe Inflammatory Skin Disease Prior Authorization Update - Jun 01, 2023
- Targeted Immune Modulators DERP summary - Oct 06, 2022
- Targeted Immune Modulators Class update with Ozanimod PA update - Oct 07, 2021
- Biologics for Autoimmune Diseases DERP summary - Oct 01, 2020
- Biologics for Autoimmune Conditions - Feb 06, 2020
- Biologics for Autoimmune Conditions - Jan 24, 2019
- Hidradenitis Suppurativa - Nov 29, 2018
- Biologics for Autoimmune Conditions - Jan 25, 2018
- Biologics for Autoimmune Conditions - Jul 27, 2017
- Biologics for Autoimmune Conditions - Sep 29, 2016
- Biologics - Sep 23, 2014
- Abbreviated Class Update: Targeted Immune Modulators (TIMs) and New Drug Evaluation: Xeljanz (tofacitinib) - Mar 28, 2013
- DERP Drug Class Review Executive Summary: TIMs - Jun 28, 2012
- P&T Committee Brief: Targeted Immune Modulators (TIMs) - Jun 28, 2012
- Conclusions and Recommendations: TIMs - Jun 28, 2012
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 | New Drug Evaluation |
---|---|---|---|---|---|
adalimumab | HUMIRA(CF) PEN | PEN IJ KIT | Y | PA Document | |
adalimumab | HUMIRA PEN | PEN IJ KIT | Y | PA Document | |
adalimumab | HUMIRA(CF) PEN CROHN'S-UC-HS | PEN IJ KIT | Y | PA Document | |
adalimumab | HUMIRA(CF) PEN PSOR-UV-ADOL HS | PEN IJ KIT | Y | PA Document | |
adalimumab | HUMIRA(CF) PEN PEDIATRIC UC | PEN IJ KIT | Y | PA Document | |
adalimumab | HUMIRA(CF) | SYRINGEKIT | Y | PA Document | |
adalimumab | HUMIRA | SYRINGEKIT | Y | PA Document | |
adalimumab-atto | AMJEVITA(CF) AUTOINJECTOR | AUTO INJCT | Y | PA Document | |
adalimumab-atto | AMJEVITA(CF) | SYRINGE | Y | PA Document | |
adalimumab-fkjp | ADALIMUMAB-FKJP(CF) PEN | PEN IJ KIT | Y | PA Document | |
adalimumab-fkjp | ADALIMUMAB-FKJP(CF) | SYRINGEKIT | Y | PA Document | |
adalimumab-ryvk | SIMLANDI(CF) AUTOINJECTOR | AUTOINJKIT | Y | PA Document | |
apremilast | OTEZLA | TAB DS PK | Y | PA Document | |
apremilast | OTEZLA | TABLET | Y | PA Document | |
etanercept | ENBREL MINI | CARTRIDGE | Y | PA Document | |
etanercept | ENBREL SURECLICK | PEN INJCTR | Y | PA Document | |
etanercept | ENBREL | SYRINGE | Y | PA Document | |
etanercept | ENBREL | VIAL | Y | PA Document | |
infliximab-axxq | AVSOLA | VIAL | Y | PA Document | |
ixekizumab | TALTZ AUTOINJECTOR | AUTO INJCT | Y | PA Document | Nov 17, 2016 |
ixekizumab | TALTZ AUTOINJECTOR (3 PACK) | AUTO INJCT | Y | PA Document | Nov 17, 2016 |
ixekizumab | TALTZ AUTOINJECTOR (2 PACK) | AUTO INJCT | Y | PA Document | Nov 17, 2016 |
ixekizumab | TALTZ SYRINGE | SYRINGE | Y | PA Document | Nov 17, 2016 |
tofacitinib citrate | XELJANZ | SOLUTION | Y | PA Document | |
tofacitinib citrate | XELJANZ XR | TAB ER 24H | Y | PA Document | |
tofacitinib citrate | XELJANZ | TABLET | Y | PA Document | |
abatacept | ORENCIA CLICKJECT | AUTO INJCT | N | PA Document | |
abatacept | ORENCIA | SYRINGE | N | PA Document | |
abatacept/maltose | ORENCIA | VIAL | N | PA Document | |
adalimumab-aacf | ADALIMUMAB-AACF(CF) PEN | PEN IJ KIT | N | PA Document | |
adalimumab-aacf | ADALIMUMAB-AACF(CF) PEN CROHNS | PEN IJ KIT | N | PA Document | |
adalimumab-aacf | ADALIMUMAB-AACF(CF) PEN PS-UV | PEN IJ KIT | N | PA Document | |
adalimumab-aacf | IDACIO(CF) PEN | PEN IJ KIT | N | PA Document | |
adalimumab-aacf | IDACIO(CF) PEN CROHN'S-UC | PEN IJ KIT | N | PA Document | |
adalimumab-aacf | IDACIO(CF) PEN PSORIASIS | PEN IJ KIT | N | PA Document | |
adalimumab-aacf | IDACIO(CF) PEN | PEN INJCTR | N | PA Document | |
adalimumab-aacf | ADALIMUMAB-AACF(CF) | SYRINGE | N | PA Document | |
adalimumab-aacf | ADALIMUMAB-AACF(CF) | SYRINGEKIT | N | PA Document | |
adalimumab-aacf | IDACIO(CF) | SYRINGEKIT | N | PA Document | |
adalimumab-aaty | YUFLYMA(CF) AUTOINJECT (2 PCK) | AUTOINJKIT | N | PA Document | |
adalimumab-aaty | YUFLYMA(CF) AI CROHN'S-UC-HS | AUTOINJKIT | N | PA Document | |
adalimumab-aaty | YUFLYMA(CF) AUTOINJECTOR | AUTOINJKIT | N | PA Document | |
adalimumab-aaty | ADALIMUMAB-AATY(CF) AUTOINJ(2) | AUTOINJKIT | N | PA Document | |
adalimumab-aaty | ADALIMUMAB-AATY(CF) AUTOINJECT | AUTOINJKIT | N | PA Document | |
adalimumab-aaty | ADALIMUMAB-AATY(CF) | SYRINGEKIT | N | PA Document | |
adalimumab-aaty | YUFLYMA(CF) | SYRINGEKIT | N | PA Document | |
adalimumab-adaz | ADALIMUMAB-ADAZ(CF) PEN | PEN INJCTR | N | PA Document | |
adalimumab-adaz | HYRIMOZ(CF) PEN | PEN INJCTR | N | PA Document | |
adalimumab-adaz | HYRIMOZ(CF) PEN PSORIASIS | PEN INJCTR | N | PA Document | |
adalimumab-adaz | HYRIMOZ(CF) PEN CROHN-UC START | PEN INJCTR | N | PA Document | |
adalimumab-adaz | ADALIMUMAB-ADAZ(CF) | SYRINGE | N | PA Document | |
adalimumab-adaz | HYRIMOZ(CF) | SYRINGE | N | PA Document | |
adalimumab-adaz | HYRIMOZ(CF) PEDIATRIC CROHN'S | SYRINGE | N | PA Document | |
adalimumab-adbm | CYLTEZO(CF) PEN CROHN'S-UC-HS | PEN IJ KIT | N | PA Document | |
adalimumab-adbm | CYLTEZO(CF) PEN PSORIASIS-UV | PEN IJ KIT | N | PA Document | |
adalimumab-adbm | ADALIMUMAB-ADBM(CF)PEN | PEN IJ KIT | N | PA Document | |
adalimumab-adbm | CYLTEZO(CF) PEN | PEN IJ KIT | N | PA Document | |
adalimumab-adbm | ADALIMUMAB-ADBM(CF) PEN | PEN IJ KIT | N | PA Document | |
adalimumab-adbm | ADALIMUMAB-ADBM(CF) PEN CROHNS | PEN IJ KIT | N | PA Document | |
adalimumab-adbm | ADALIMUMAB-ADBM(CF) PEN PS-UV | PEN IJ KIT | N | PA Document | |
adalimumab-adbm | CYLTEZO(CF) | SYRINGEKIT | N | PA Document | |
adalimumab-adbm | ADALIMUMAB-ADBM(CF) | SYRINGEKIT | N | PA Document | |
adalimumab-afzb | ABRILADA(CF) PEN | PEN IJ KIT | N | PA Document | |
adalimumab-afzb | ABRILADA(CF) | SYRINGEKIT | N | PA Document | |
adalimumab-aqvh | YUSIMRY(CF) PEN | PEN INJCTR | N | PA Document | |
adalimumab-atto | AMJEVITA(CF) AUTOINJECTOR | AUTO INJCT | N | PA Document | |
adalimumab-atto | AMJEVITA(CF) | SYRINGE | N | PA Document | |
adalimumab-bwwd | HADLIMA PUSHTOUCH | AUTO INJCT | N | PA Document | |
adalimumab-bwwd | HADLIMA(CF) PUSHTOUCH | AUTO INJCT | N | PA Document | |
adalimumab-bwwd | HADLIMA | SYRINGE | N | PA Document | |
adalimumab-bwwd | HADLIMA(CF) | SYRINGE | N | PA Document | |
adalimumab-fkjp | ADALIMUMAB-FKJP(CF) PEN | PEN IJ KIT | N | PA Document | |
adalimumab-fkjp | HULIO(CF) PEN | PEN IJ KIT | N | PA Document | |
adalimumab-fkjp | ADALIMUMAB-FKJP(CF) PEN | PEN INJCTR | N | PA Document | |
adalimumab-fkjp | HULIO(CF) PEN | PEN INJCTR | N | PA Document | |
adalimumab-fkjp | ADALIMUMAB-FKJP(CF) | SYRINGE | N | PA Document | |
adalimumab-fkjp | HULIO(CF) | SYRINGE | N | PA Document | |
adalimumab-fkjp | ADALIMUMAB-FKJP(CF) | SYRINGEKIT | N | PA Document | |
adalimumab-fkjp | HULIO(CF) | SYRINGEKIT | N | PA Document | |
adalimumab-ryvk | ADALIMUMAB-RYVK(CF) AUTOINJECT | AUTOINJKIT | N | PA Document | |
adalimumab-ryvk | ADALIMUMAB-RYVK(CF) | SYRINGEKIT | N | PA Document | |
adalimumab-ryvk | SIMLANDI(CF) | SYRINGEKIT | N | PA Document | |
anakinra | KINERET | SYRINGE | N | PA Document | |
baricitinib | OLUMIANT | TABLET | N | PA Document | |
bimekizumab-bkzx | BIMZELX AUTOINJECTOR | AUTO INJCT | N | PA Document | |
bimekizumab-bkzx | BIMZELX | SYRINGE | N | PA Document | |
brodalumab | SILIQ | SYRINGE | N | PA Document | |
canakinumab/PF | ILARIS | VIAL | N | PA Document | |
certolizumab pegol | CIMZIA | KIT | N | PA Document | |
certolizumab pegol | CIMZIA | SYRINGEKIT | N | PA Document | |
deucravacitinib | SOTYKTU | TABLET | N | PA Document | |
etrasimod arginine | VELSIPITY | TABLET | N | PA Document | |
golimumab | SIMPONI | PEN INJCTR | N | PA Document | |
golimumab | SIMPONI | SYRINGE | N | PA Document | |
golimumab | SIMPONI ARIA | VIAL | N | PA Document | |
guselkumab | TREMFYA | AUTO INJCT | N | PA Document | |
guselkumab | TREMFYA PEN | PEN INJCTR | N | PA Document | |
guselkumab | TREMFYA | SYRINGE | N | PA Document | |
guselkumab | TREMFYA | VIAL | N | PA Document | |
infliximab | INFLIXIMAB | VIAL | N | PA Document | |
infliximab | REMICADE | VIAL | N | PA Document | |
infliximab-abda | RENFLEXIS | VIAL | N | PA Document | |
infliximab-dyyb | ZYMFENTRA | PEN IJ KIT | N | PA Document | |
infliximab-dyyb | ZYMFENTRA (2 PENS) | PEN IJ KIT | N | PA Document | |
infliximab-dyyb | ZYMFENTRA (2 SYRINGES) | SYRINGEKIT | N | PA Document | |
infliximab-dyyb | INFLECTRA | VIAL | N | PA Document | |
mirikizumab-mrkz | OMVOH PEN | PEN INJCTR | N | PA Document | |
mirikizumab-mrkz | OMVOH | SYRINGE | N | PA Document | |
mirikizumab-mrkz | OMVOH | VIAL | N | PA Document | |
natalizumab | TYSABRI | VIAL | N | PA Document | |
risankizumab-rzaa | SKYRIZI PEN | PEN INJCTR | N | PA Document | |
risankizumab-rzaa | SKYRIZI | SYRINGE | N | PA Document | |
risankizumab-rzaa | SKYRIZI | VIAL | N | PA Document | |
risankizumab-rzaa | SKYRIZI ON-BODY | WEAR INJCT | N | PA Document | |
rituximab | RITUXAN | VIAL | N | PA Document | |
rituximab-abbs | TRUXIMA | VIAL | N | PA Document | |
rituximab-arrx | RIABNI | VIAL | N | PA Document | |
rituximab-pvvr | RUXIENCE | VIAL | N | PA Document | |
sarilumab | KEVZARA | PEN INJCTR | N | PA Document | |
sarilumab | KEVZARA | SYRINGE | N | PA Document | |
secukinumab | COSENTYX SENSOREADY PEN | PEN INJCTR | N | PA Document | Jul 30, 2015 |
secukinumab | COSENTYX SENSOREADY (2 PENS) | PEN INJCTR | N | PA Document | Jul 30, 2015 |
secukinumab | COSENTYX UNOREADY PEN | PEN INJCTR | N | PA Document | Jul 30, 2015 |
secukinumab | COSENTYX SYRINGE | SYRINGE | N | PA Document | Jul 30, 2015 |
secukinumab | COSENTYX (2 SYRINGES) | SYRINGE | N | PA Document | Jul 30, 2015 |
secukinumab | COSENTYX | VIAL | N | PA Document | Jul 30, 2015 |
spesolimab-sbzo | SPEVIGO | SYRINGE | N | PA Document | |
spesolimab-sbzo | SPEVIGO | VIAL | N | PA Document | |
tildrakizumab-asmn | ILUMYA | SYRINGE | N | PA Document | |
tocilizumab | ACTEMRA ACTPEN | PEN INJCTR | N | PA Document | |
tocilizumab | ACTEMRA | SYRINGE | N | PA Document | |
tocilizumab | ACTEMRA | VIAL | N | PA Document | |
tocilizumab-aazg | TYENNE AUTOINJECTOR | PEN INJCTR | N | PA Document | |
tocilizumab-aazg | TYENNE | SYRINGE | N | PA Document | |
tocilizumab-aazg | TYENNE | VIAL | N | PA Document | |
tocilizumab-bavi | TOFIDENCE | VIAL | N | PA Document | |
upadacitinib | RINVOQ LQ | SOLUTION | N | PA Document | |
upadacitinib | RINVOQ | TAB ER 24H | N | PA Document | |
ustekinumab | STELARA | SYRINGE | N | PA Document | |
ustekinumab | STELARA | VIAL | N | PA Document | |
vedolizumab | ENTYVIO PEN | PEN INJCTR | N | PA Document | |
vedolizumab | ENTYVIO | VIAL | N | PA Document | |
ustekinumab-kfce | YESINTEK | SYRINGE | PA Document | ||
ustekinumab-kfce | YESINTEK | VIAL | PA Document |