Biologicals

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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 but eligible patients will encounter a co-pay at the pharmacy.
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
immun glob G(IgG)-ifas/glycine PANZYGA VIAL N    
adenovirus live types-4,7 vacc ADENOVIRUS TYPE 4 AND TYPE 7 TABLET DR    
adenovirus vaccine live type-4 ADENOVIRUS TYPE 4 TABLET DR    
adenovirus vaccine live type-7 ADENOVIRUS TYPE 7 TABLET DR    
bacterial vaccines,mixed MRV VIAL    
BCG vaccine, live/PF BCG VACCINE (TICE STRAIN) VIAL    
burosumab-twza CRYSVITA VIAL    
cytomegalovirus immune globuln CYTOGAM VIAL    
diph,pertus(acel),tet,polio/PF QUADRACEL DTAP-IPV VIAL    
diph,pertuss(acell),tet ped/PF DAPTACEL DTAP VIAL    
diph,pertuss(acell),tet vac/PF ADACEL TDAP SYRINGE    
diph,pertuss(acell),tet vac/PF ADACEL TDAP VIAL    
dipht,pert(a),tet-polio/Hib/PF PENTACEL KIT    
DTaP-IPV component 1 of 2/PF PENTACEL DTAP-IPV COMPONENT VIAL    
Haemoph b poly conj-tet tox/PF ACTHIB VIAL    
Haemph b polysac conj-menin/PF PEDVAXHIB VIAL    
hepatitis A virus vaccine/PF VAQTA SYRINGE    
hepatitis A virus vaccine/PF VAQTA VIAL    
hepatitis B immun glob/maltose HEPAGAM B VIAL    
hepatitis B immune globulin H-BIG SYRINGE    
hepatitis B immune globulin HYPERHEP B S-D SYRINGE    
hepatitis B immune globulin HYPERHEP B S-D VIAL    
hepatitis B immune globulin H-BIG VIAL    
hepatitis B immune globulin NABI-HB VIAL    
hepatitis B virus vaccine/PF RECOMBIVAX HB SYRINGE    
hepatitis B virus vaccine/PF RECOMBIVAX HB VIAL    
Hib conj-tet,component 2of2/PF PENTACEL ACTHIB COMPONENT VIAL    
histoplasmin HISTOPLASMIN VIAL    
HPV vaccine 9-valent/PF GARDASIL 9 SYRINGE    
HPV vaccine 9-valent/PF GARDASIL 9 VIAL    
human papilomvirus vac,qval/PF GARDASIL SYRINGE    
human papilomvirus vac,qval/PF GARDASIL VIAL    
immun glob G(IgG)-hipp/maltose CUTAQUIG VIAL    
immun glob G(IgG)/gly/IgA 0-50 GAMMAPLEX VIAL    
measles,mumps,rub,varicella/PF PROQUAD VIAL    
measles,mumps,rubella vacc/PF M-M-R II VACCINE VIAL    
mening vac A,C,Y,W-135 dip/PF MENACTRA VIAL    
Meningococ Vac A,C,Y,W-135/PF MENOMUNE-A-C-Y-W-135 VIAL    
meningococcal vac A,C,Y,W-135 MENOMUNE-A-C-Y-W-135 VIAL    
pneumococcal 23-val p-sac vac PNEUMOVAX 23 SYRINGE    
pneumococcal 23-val p-sac vac PNEUMOVAX 23 VIAL    
poliomyelitis vaccine, killed IPOL SYRINGE    
poliomyelitis vaccine, killed IPOL VIAL    
rabies immune globulin/PF KEDRAB VIAL    
rabies immune globulin/PF IMOGAM RABIES-HT VIAL    
rabies immune globulin/PF HYPERRAB S-D VIAL    
rabies immune globulin/PF HYPERRAB VIAL    
rabies vac,ads.,rhesus monkey RABIES VACCINE ADSORBED VIAL    
rabies vacc, human diploid/PF IMOVAX RABIES VACCINE VIAL    
Rho(D) immune globulin RHOPHYLAC SYRINGE    
Rho(D) immune globulin RHOGAM ULTRA-FILTERED PLUS SYRINGE    
Rho(D) immune globulin MICRHOGAM ULTRA-FILTERED PLUS SYRINGE    
Rho(D) immune globulin HYPERRHO S-D SYRINGE    
Rho(D) immune globulin/maltose WINRHO SDF VIAL    
rotavirus vaccine,live oral pv ROTATEQ SOLUTION    
tetanus immune globulin/PF HYPERTET S-D SYRINGE    
tetanus toxoid, adsorbed TETANUS TOXOID SYRINGE    
tetanus-diphtheria toxoids/PF TENIVAC SYRINGE    
tetanus-diphtheria toxoids/PF TENIVAC VIAL    
tetanus, diphtheria tox,adult TETANUS DIPHTHERIA SYRINGE    
tetanus, diphtheria tox,adult TETANUS DIPHTHERIA TOXOIDS VIAL    
tetanus,diphtheria toxd ped/PF DIPHTHERIA-TETANUS TOXOIDS-PED VIAL    
tetanus,diphtheria toxoid ped DIPHTHERIA/TETANUS TOXOIDS SYRINGE    
tetanus,diphtheria toxoid ped DIPHTHERIA/TETANUS TOXOIDS VIAL    
tetanus,diphtheria toxoid ped DIPHTHERIA/TETANUS TOXOID VIAL    
tuberculin,purif.prot.deriv. TUBERSOL VIAL    
tuberculin,purif.prot.deriv. APLISOL VIAL    
typhoid VI polysacch vaccine TYPHIM VI SYRINGE    
typhoid VI polysacch vaccine TYPHIM VI VIAL    
varicella vaccine live/PF VARIVAX VACCINE VIAL    
varicella-zoster Ig/maltose VARIZIG VIAL    
varicella-zoster immune glob VARIZIG VIAL    
yellow fever vaccine live/PF YF-VAX VIAL    
zoster vaccine live/PF ZOSTAVAX VIAL