Immunotherapy Desensitization, non-injectable
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 |
|---|---|---|---|---|---|
| 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 |