Hereditary Angioedema

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PDL Reference 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 but eligible patients will encounter a co-pay at the pharmacy.
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
C1 esterase inhibitor BERINERT KIT PA Document  
C1 esterase inhibitor HAEGARDA VIAL PA Document  
C1 esterase inhibitor CINRYZE VIAL PA Document  
C1 esterase inhibitor BERINERT VIAL PA Document  
C1 esterase inhibitor, recomb RUCONEST VIAL PA Document  
ecallantide KALBITOR VIAL PA Document  
icatibant acetate FIRAZYR SYRINGE PA Document  
lanadelumab-flyo TAKHZYRO VIAL PA Document