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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| eculizumab-aagh | EPYSQLI | VIAL | N | Pharmacy PA | N | |
| iptacopan HCl | FABHALTA | CAPSULE | N | Pharmacy PA | N | |
| ADAMTS13, recombinant-krhn | ADZYNMA | KIT | Pharmacy PA | N | ||
| alpelisib | VIJOICE | GRAN PACK | Pharmacy PA | N | ||
| alpelisib | VIJOICE | TABLET | Pharmacy PA | N | ||
| arimoclomol citrate | MIPLYFFA | CAPSULE | Pharmacy PA | N | ||
| atidarsagene autotemcel | LENMELDY | PLAST. BAG | Pharmacy PA | N | ||
| axatilimab-csfr | NIKTIMVO | VIAL | Pharmacy PA | N | ||
| beremagene geperpavec-svdt | VYJUVEK | GEL (ML) | Pharmacy PA | N | ||
| cerliponase alfa | BRINEURA | KIT | Pharmacy PA | N | Jun 04, 2020 Feb 04, 2021 |
|
| danicopan | VOYDEYA | TABLET | Pharmacy PA | N | ||
| eladocagene exuparvovec-tneq | KEBILIDI | VIAL | Pharmacy PA | N | ||
| elapegademase-lvlr | REVCOVI | VIAL | Pharmacy PA | N | Feb 04, 2021 | |
| fosdenopterin hydrobromide | NULIBRY | VIAL | Pharmacy PA | N | Jun 03, 2021 | |
| givosiran sodium | GIVLAARI | VIAL | Pharmacy PA | N | Feb 04, 2021 | |
| inebilizumab-cdon | UPLIZNA | VIAL | Pharmacy PA | N | ||
| leniolisib phosphate | JOENJA | TABLET | Pharmacy PA | N | ||
| lumasiran sodium | OXLUMO | VIAL | Pharmacy PA | N | Feb 04, 2021 | |
| luspatercept-aamt | REBLOZYL | VIAL | Pharmacy PA | N | Jun 04, 2020 Feb 04, 2021 |
|
| mavacamten | CAMZYOS | CAPSULE | Pharmacy PA | N | ||
| mirdametinib | GOMEKLI | CAPSULE | Pharmacy PA | N | ||
| mirdametinib | GOMEKLI | TAB SUSP | Pharmacy PA | N | ||
| nedosiran sodium | RIVFLOZA | SYRINGE | Pharmacy PA | N | ||
| nedosiran sodium | RIVFLOZA | VIAL | Pharmacy PA | N | ||
| odevixibat | BYLVAY | CAPSULE | Pharmacy PA | N | ||
| olipudase alfa-rpcp | XENPOZYME | VIAL | Pharmacy PA | N | ||
| palopegteriparatide | YORVIPATH | PEN INJCTR | Pharmacy PA | N | ||
| palovarotene | SOHONOS | CAPSULE | Pharmacy PA | N | ||
| plasminogen, human-tvmh | RYPLAZIM | VIAL | Pharmacy PA | N | ||
| remestemcel-L-rknd | RYONCIL | KIT | Pharmacy PA | N | ||
| remestemcel-L-rknd | RYONCIL | VIAL | Pharmacy PA | N | ||
| rezafungin acetate | REZZAYO | VIAL | Pharmacy PA | N | ||
| satralizumab-mwge | ENSPRYNG | SYRINGE | Pharmacy PA | N | ||
| tofersen | QALSODY | VIAL | Pharmacy PA | N |