Targeted Immune Modulators for Asthma and Atopic Dermatitis

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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 & Updates
abrocitinib CIBINQO TABLET N PA Document  
benralizumab FASENRA PEN AUTO INJCT N PA Document  
benralizumab FASENRA SYRINGE N PA Document  
dupilumab DUPIXENT PEN PEN INJCTR N PA Document  
dupilumab DUPIXENT SYRINGE SYRINGE N PA Document  
lebrikizumab-lbkz EBGLYSS PEN PEN INJCTR N PA Document  
lebrikizumab-lbkz EBGLYSS SYRINGE SYRINGE N PA Document  
mepolizumab NUCALA AUTO INJCT N PA Document  
mepolizumab NUCALA SYRINGE N PA Document  
mepolizumab NUCALA VIAL N PA Document  
nemolizumab-ilto NEMLUVIO PEN INJCTR N PA Document  
omalizumab XOLAIR AUTO INJCT N PA Document  
omalizumab XOLAIR SYRINGE N PA Document  
omalizumab XOLAIR VIAL N PA Document  
reslizumab CINQAIR VIAL N PA Document  
tezepelumab-ekko TEZSPIRE PEN INJCTR N PA Document  
tezepelumab-ekko TEZSPIRE SYRINGE N PA Document  
tralokinumab-ldrm ADBRY AUTOINJECTOR AUTO INJCT N PA Document  
tralokinumab-ldrm ADBRY SYRINGE N PA Document  
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