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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
Current Drug Use Criteria New Drug Evaluation
sapropterin dihydrochloride KUVAN TABLET SOL N PA Document Jul 25, 2013
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