Orphan Drug
Drug Use Review 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 |
|---|---|---|---|---|---|
| belumosudil mesylate | REZUROCK | TABLET | N | PA Document | Oct 07, 2021 |
| iptacopan HCl | FABHALTA | CAPSULE | N | PA Document | |
| zilucoplan sodium | ZILBRYSQ | SYRINGE | N | PA Document | |
| ADAMTS13, recombinant-krhn | ADZYNMA | KIT | PA Document | ||
| alpelisib | VIJOICE | GRAN PACK | PA Document | ||
| alpelisib | VIJOICE | TABLET | PA Document | ||
| arimoclomol citrate | MIPLYFFA | CAPSULE | PA Document | ||
| avacopan | TAVNEOS | CAPSULE | PA Document | ||
| beremagene geperpavec-svdt | VYJUVEK | GEL (ML) | PA Document | ||
| burosumab-twza | CRYSVITA | VIAL | PA Document | Jun 04, 2020 Feb 04, 2021 |
|
| cerliponase alfa | BRINEURA | KIT | PA Document | Jun 04, 2020 Feb 04, 2021 |
|
| cerliponase alfa | BRINEURA | VIAL | PA Document | Jun 04, 2020 Feb 04, 2021 |
|
| crovalimab-akkz | PIASKY | VIAL | PA Document | ||
| danicopan | VOYDEYA | TABLET | PA Document | ||
| eculizumab | SOLIRIS | VIAL | PA Document | ||
| eculizumab-aeeb | BKEMV | VIAL | PA Document | ||
| eladocagene exuparvovec-tneq | KEBILIDI | VIAL | PA Document | ||
| elapegademase-lvlr | REVCOVI | VIAL | PA Document | Feb 04, 2021 | |
| elivaldogene autotemcel | SKYSONA | PLAST. BAG | PA Document | ||
| fosdenopterin hydrobromide | NULIBRY | VIAL | PA Document | Jun 03, 2021 | |
| givosiran sodium | GIVLAARI | VIAL | PA Document | Feb 04, 2021 | |
| inebilizumab-cdon | UPLIZNA | VIAL | PA Document | ||
| leniolisib phosphate | JOENJA | TABLET | PA Document | ||
| levacetylleucine | AQNEURSA | GRAN PACK | PA Document | ||
| levoketoconazole | RECORLEV | TABLET | PA Document | ||
| lonafarnib | ZOKINVY | CAPSULE | PA Document | Feb 04, 2021 | |
| lumasiran sodium | OXLUMO | VIAL | PA Document | Feb 04, 2021 | |
| luspatercept-aamt | REBLOZYL | VIAL | PA Document | Jun 04, 2020 Feb 04, 2021 |
|
| maralixibat chloride | LIVMARLI | SOLUTION | PA Document | ||
| mavorixafor | XOLREMDI | CAPSULE | PA Document | ||
| mitapivat sulfate | PYRUKYND | TAB DS PK | PA Document | ||
| mitapivat sulfate | PYRUKYND | TABLET | PA Document | ||
| nedosiran sodium | RIVFLOZA | SYRINGE | PA Document | ||
| nedosiran sodium | RIVFLOZA | VIAL | PA Document | ||
| odevixibat | BYLVAY | CAPSULE | PA Document | ||
| odevixibat | BYLVAY | PEL DSP CP | PA Document | ||
| olipudase alfa-rpcp | XENPOZYME | VIAL | PA Document | ||
| palovarotene | SOHONOS | CAPSULE | PA Document | ||
| pegcetacoplan | EMPAVELI | VIAL | PA Document | ||
| plasminogen, human-tvmh | RYPLAZIM | VIAL | PA Document | ||
| pozelimab-bbfg | VEOPOZ | VIAL | PA Document | ||
| ravulizumab-cwvz | ULTOMIRIS | VIAL | PA Document | ||
| rozanolixizumab-noli | RYSTIGGO | VIAL | PA Document | ||
| satralizumab-mwge | ENSPRYNG | SYRINGE | PA Document | ||
| sodium thiosulfate | PEDMARK | VIAL | PA Document | ||
| sutimlimab-jome | ENJAYMO | VIAL | PA Document | ||
| tofersen | QALSODY | VIAL | PA Document | ||
| trientine tetrahydrochloride | CUVRIOR | TABLET | PA Document | ||
| velmanase alfa-tycv | LAMZEDE | VIAL | PA Document |