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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
Current Drug Use Criteria New Drug Evaluation
collagenase Clostridium hist. XIAFLEX VIAL    
hyaluronidase AMPHADASE VIAL    
hyaluronidase, human recomb. HYLENEX VIAL    
hyaluronidase, human recomb. HYQVIA HY COMPONENT VIAL    
hyaluronidase,ovine VITRASE VIAL