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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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
lenacapavir sodium YEZTUGO TABLET Y   N  
lenacapavir sodium YEZTUGO VIAL Y   N  
acyclovir sodium ACYCLOVIR SODIUM VIAL   N  
atoltivimab-maftiv-odesiv-ebgn INMAZEB (NATIONAL STOCKPILE) VIAL   N  
cidofovir CIDOFOVIR VIAL   N  
cilgavimab CILGAVIMAB (EUA) VIAL   N  
clesrovimab-cfor ENFLONSIA SYRINGE   N  
foscarnet sodium FOSCARNET SODIUM INFUS. BTL   N  
foscarnet sodium FOSCARNET SODIUM PLAST. BAG   N  
ganciclovir sodium GANCICLOVIR SODIUM VIAL   N  
letermovir PREVYMIS PELET PACK   N  
letermovir PREVYMIS TABLET   N  
letermovir PREVYMIS VIAL   N  
maribavir LIVTENCITY TABLET   N  
palivizumab SYNAGIS VIAL Pharmacy PA N Sep 26, 2013
Sep 23, 2014
Feb 03, 2022
Oct 05, 2023
ribavirin RIBAVIRIN VIAL-NEB   N  
sinecatechins VEREGEN OINT. (G)   N  
tixagevimab TIXAGEVIMAB (EUA) VIAL   N  
tixagevimab/cilgavimab EVUSHELD (EUA) VIAL   N  
valganciclovir HCl VALCYTE SOLN RECON   N  
valganciclovir HCl VALGANCICLOVIR HCL SOLN RECON   N  
valganciclovir HCl VALCYTE TABLET   N  
valganciclovir HCl VALGANCICLOVIR HCL TABLET   N  
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