Iron Replacemant & Hematinics, Not Oral

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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
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