Immunotherapy Desensitization, non-injectable

← Back to Class List

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
gr pol-orc/sw ver/rye/Kent/tim ORALAIR TAB SUBL N PA Document  
grass pollen-timothy, standard GRASTEK TAB SUBL N PA Document  
mite,D.farinae-D.pteronyssinus ODACTRA TAB SUBL N PA Document  
peanut allergen powder-dnfp PALFORZIA CAP SPRINK N PA Document Feb 04, 2021
peanut allergen powder-dnfp PALFORZIA POWD PACK N PA Document Feb 04, 2021
weed pollen-short ragweed RAGWITEK TAB SUBL N PA Document