Phenylketonuria
Drug Use Review 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 & Updates |
|---|---|---|---|---|---|
| sapropterin dihydrochloride | KUVAN | TABLET SOL | N | PA Document | Jul 25, 2013 May 26, 2016 |
| sapropterin dihydrochloride | JAVYGTOR | TABLET SOL | N | PA Document | |
| sapropterin dihydrochloride | SAPROPTERIN DIHYDROCHLORIDE | TABLET SOL | N | PA Document | |
| pegvaliase-pqpz | PALYNZIQ | SYRINGE | PA Document | Sep 27, 2018 | |
| sapropterin dihydrochloride | SAPROPTERIN DIHYDROCHLORIDE | POWD PACK | PA Document | ||
| sapropterin dihydrochloride | JAVYGTOR | POWD PACK | PA Document | ||
| sapropterin dihydrochloride | KUVAN | POWD PACK | PA Document | May 26, 2016 |