Orphan Drug

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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
belumosudil mesylate REZUROCK TABLET N PA Document Oct 07, 2021
alpelisib VIJOICE TABLET PA Document  
avacopan TAVNEOS CAPSULE PA Document  
burosumab-twza CRYSVITA VIAL PA Document Feb 04, 2021
cerliponase alfa BRINEURA KIT PA Document Feb 04, 2021
cerliponase alfa BRINEURA VIAL PA Document Feb 04, 2021
elapegademase-lvlr REVCOVI VIAL PA Document Feb 04, 2021
fosdenopterin hydrobromide NULIBRY VIAL PA Document Jun 03, 2021
givosiran sodium GIVLAARI VIAL PA Document Feb 04, 2021
lonafarnib ZOKINVY CAPSULE PA Document Feb 04, 2021
lumasiran sodium OXLUMO VIAL PA Document Feb 04, 2021
luspatercept-aamt REBLOZYL VIAL PA Document Feb 04, 2021
maralixibat chloride LIVMARLI SOLUTION PA Document  
mitapivat sulfate PYRUKYND TAB DS PK PA Document  
mitapivat sulfate PYRUKYND TABLET PA Document  
odevixibat BYLVAY CAPSULE PA Document  
odevixibat BYLVAY PEL DSP CP PA Document  
plasminogen, human-tvmh RYPLAZIM VIAL PA Document  
sutimlimab-jome ENJAYMO VIAL PA Document