Biologics for Rare Conditions
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.
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 |
|---|---|---|---|---|---|
| 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 |