Biologics for Rare Conditions

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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
inebilizumab-cdon UPLIZNA VIAL Y PA Document  
ravulizumab-cwvz ULTOMIRIS VIAL Y PA Document  
satralizumab-mwge ENSPRYNG SYRINGE Y PA Document  
eculizumab SOLIRIS VIAL N PA Document  
efgartigimod alfa-fcab VYVGART VIAL N PA Document Apr 07, 2022
pegcetacoplan EMPAVELI VIAL N PA Document  
efgartigimod-hyaluronidas-qvfc VYVGART HYTRULO VIAL    
pozelimab-bbfg VEOPOZ VIAL    
rozanolixizumab-noli RYSTIGGO VIAL PA Document