Misc Antivirals
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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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| acyclovir sodium | ACYCLOVIR SODIUM | VIAL | ||||
| atoltivimab-maftiv-odesiv-ebgn | INMAZEB (NATIONAL STOCKPILE) | VIAL | ||||
| bulevirtide acetate-gmod | HEPCLUDEX | VIAL | ||||
| cidofovir | CIDOFOVIR | VIAL | ||||
| clesrovimab-cfor | ENFLONSIA | SYRINGE | ||||
| doravirine/islatravir | IDVYNSO | TABLET | ||||
| foscarnet sodium | FOSCARNET SODIUM | INFUS. BTL | ||||
| foscarnet sodium | FOSCARNET SODIUM | PLAST. BAG | ||||
| ganciclovir sodium | GANCICLOVIR SODIUM | VIAL | ||||
| letermovir | PREVYMIS | PELET PACK | ||||
| letermovir | PREVYMIS | TABLET | ||||
| letermovir | PREVYMIS | VIAL | ||||
| maribavir | LIVTENCITY | TABLET | ||||
| palivizumab | SYNAGIS | VIAL | Pharmacy PA | Sep 26, 2013 Sep 23, 2014 Feb 03, 2022 Oct 05, 2023 |
||
| ribavirin | RIBAVIRIN | VIAL-NEB | ||||
| sinecatechins | VEREGEN | OINT. (G) | ||||
| valganciclovir HCl | VALCYTE | SOLN RECON | ||||
| valganciclovir HCl | VALGANCICLOVIR HCL | SOLN RECON | ||||
| valganciclovir HCl | VALGANCICLOVIR HCL | TABLET |