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 New Drug Evaluation
fostemsavir tromethamine RUKOBIA TAB ER 12H Y    
acyclovir sodium ACYCLOVIR SODIUM VIAL    
bamlanivimab BAMLANIVIMAB (EUA) VIAL    
bebtelovimab BEBTELOVIMAB (EUA) VIAL    
casirivimab CASIRIVIMAB (REGN10933) (EUA) VIAL    
casirivimab/imdevimab REGEN-COV (EUA) VIAL    
casirivimab/imdevimab CASIRIVIMAB-IMDEVIMAB (EUA) VIAL    
cidofovir CIDOFOVIR VIAL    
cilgavimab CILGAVIMAB (EUA) VIAL    
etesevimab ETESEVIMAB (EUA) VIAL    
foscarnet sodium FOSCARNET SODIUM INFUS. BTL    
foscarnet sodium FOSCARNET SODIUM PLAST. BAG    
ganciclovir GANCICLOVIR PLAST. BAG    
ganciclovir sodium GANCICLOVIR SODIUM VIAL    
imdevimab IMDEVIMAB (REGN10987) (EUA) VIAL    
letermovir PREVYMIS TABLET    
letermovir PREVYMIS VIAL    
molnupiravir LAGEVRIO (EUA) CAPSULE    
nirmatrelvir/ritonavir PAXLOVID (EUA) TAB DS PK    
palivizumab SYNAGIS VIAL PA Document  
remdesivir REMDESIVIR (EUA) VIAL    
remdesivir VEKLURY VIAL    
ribavirin RIBAVIRIN VIAL-NEB    
ribavirin VIRAZOLE VIAL-NEB    
sinecatechins VEREGEN OINT. (G)    
sotrovimab SOTROVIMAB (EUA) VIAL    
tixagevimab TIXAGEVIMAB (EUA) VIAL    
tixagevimab/cilgavimab EVUSHELD (EUA) VIAL    
valganciclovir HCl VALGANCICLOVIR HCL SOLN RECON    
valganciclovir HCl VALCYTE SOLN RECON    
valganciclovir HCl VALGANCICLOVIR HCL TABLET    
valganciclovir HCl VALCYTE TABLET