Lysosomal Storage Disorders

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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
taliglucerase alfa ELELYSO VIAL Y PA Document  
agalsidase beta FABRAZYME VIAL N PA Document  
alglucosidase alfa LUMIZYME VIAL N PA Document Apr 01, 2021
avalglucosidase alfa-ngpt NEXVIAZYME VIAL N PA Document  
eliglustat tartrate CERDELGA CAPSULE N PA Document  
imiglucerase CEREZYME VIAL N PA Document  
migalastat HCl GALAFOLD CAPSULE N PA Document  
miglustat ZAVESCA CAPSULE N PA Document  
miglustat MIGLUSTAT CAPSULE N PA Document  
velaglucerase alfa VPRIV VIAL N PA Document  
elosulfase alfa VIMIZIM VIAL    
galsulfase NAGLAZYME VIAL    
idursulfase ELAPRASE VIAL    
laronidase ALDURAZYME VIAL    
sebelipase alfa KANUMA VIAL    
vestronidase alfa-vjbk MEPSEVII VIAL