Amyotrophic Lateral Sclerosis
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 |
|---|---|---|---|---|---|
| riluzole | RILUZOLE | TABLET | Y | ||
| riluzole | RILUTEK | TABLET | Y | ||
| edaravone | RADICAVA ORS | ORAL SUSP | N | PA Document | |
| edaravone | RADICAVA | PIGGYBACK | N | PA Document | Jul 26, 2018 |
| riluzole | EXSERVAN | FILM | N | ||
| riluzole | TIGLUTIK | ORAL SUSP | N | ||
| riluzole | TEGLUTIK | ORAL SUSP | N | ||
| sod phenylbutyrat/taurursodiol | RELYVRIO | POWD PACK | N | PA Document | |
| tofersen | QALSODY | VIAL | PA Document |