Iron Replacemant & Hematinics, Not Oral
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 |
|---|---|---|---|---|---|
| daprodustat | JESDUVROQ | TABLET | N | ||
| betibeglogene autotemcel | ZYNTEGLO | PLAST. BAG | PA Document | Oct 05, 2023 | |
| elivaldogene autotemcel | SKYSONA | PLAST. BAG | PA Document | ||
| ferric carboxymaltose | INJECTAFER | VIAL | |||
| ferric derisomaltose | MONOFERRIC | VIAL | |||
| ferric pyrophosphate citrate | TRIFERIC | AMPUL | |||
| ferumoxytol | FERAHEME | VIAL | |||
| ferumoxytol | FERUMOXYTOL | VIAL | |||
| iron sucrose complex | VENOFER | VIAL | |||
| plerixafor | PLERIXAFOR | VIAL | |||
| plerixafor | MOZOBIL | VIAL | |||
| sodium ferric gluconat/sucrose | SOD FERRIC GLUCONATE COMPLEX | VIAL | |||
| sodium ferric gluconat/sucrose | FERRLECIT | VIAL |