Targeted Immune Modulators for Asthma and Atopic Dermatitis
PDL Reference Documents
- COPD Class Update - Dec 05, 2024
- Omalizumab for Allergies PA Update - Aug 01, 2024
- Severe Inflammatory Skin Disease Prior Authorization Update - Jun 01, 2023
- Dupilumab (Dupixent) - Oct 06, 2022
- TIMs for Asthma - Jun 02, 2022
- Therapeutics for Atopic Dermatitis and Inflammatory Skin Conditions - Jun 02, 2022
- Biologics in Asthma - Aug 05, 2021
- Asthma and COPD maintenance medications - Oct 01, 2020
- Asthma Biologics - Jul 26, 2018
- Monoclonal Antibodies for Asthma - Jul 28, 2016
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 |