CGRP Inhibitors
PDL Reference Documents
Drug Use Review Documents
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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 Status |
Current Drug Use Criteria | New Drug Evaluation & Updates |
|---|---|---|---|---|---|
| erenumab-aooe | AIMOVIG AUTOINJECTOR | AUTO INJCT | Y | PA Document | Sep 27, 2018 |
| fremanezumab-vfrm | AJOVY AUTOINJECTOR | AUTO INJCT | Y | PA Document | |
| fremanezumab-vfrm | AJOVY SYRINGE | SYRINGE | Y | PA Document | |
| ubrogepant | UBRELVY | TABLET | Y | PA Document | |
| atogepant | QULIPTA | TABLET | N | PA Document | |
| eptinezumab-jjmr | VYEPTI | VIAL | N | PA Document | |
| galcanezumab-gnlm | EMGALITY PEN | PEN INJCTR | N | PA Document | |
| galcanezumab-gnlm | EMGALITY SYRINGE | SYRINGE | N | PA Document | |
| rimegepant sulfate | NURTEC ODT | TAB RAPDIS | N | PA Document | |
| zavegepant HCl | ZAVZPRET | SPRAY | N | PA Document |