Colony Stimulating Factors

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PDL Reference Documents

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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
72893001602 RYZNEUTA efbemalenograstim alfa-vuxw SYRINGE 20 mg/mL N Y  
76961010101 ROLVEDON eflapegrastim-xnst SYRINGE 13.2 mg/0.6 mL N Y  
55513092401 NEUPOGEN filgrastim SYRINGE 300 mcg/0.5 mL Y Y  
55513092410 NEUPOGEN filgrastim SYRINGE 300 mcg/0.5 mL Y Y  
55513092491 NEUPOGEN filgrastim SYRINGE 300 mcg/0.5 mL Y Y  
55513020901 NEUPOGEN filgrastim SYRINGE 480 mcg/0.8 mL Y Y  
55513020910 NEUPOGEN filgrastim SYRINGE 480 mcg/0.8 mL Y Y  
55513020991 NEUPOGEN filgrastim SYRINGE 480 mcg/0.8 mL Y Y  
55513053001 NEUPOGEN filgrastim VIAL 300 mcg/mL Y Y  
55513053010 NEUPOGEN filgrastim VIAL 300 mcg/mL Y Y  
55513054601 NEUPOGEN filgrastim VIAL 480 mcg/1.6 mL Y Y  
55513054610 NEUPOGEN filgrastim VIAL 480 mcg/1.6 mL Y Y  
00069029101 NIVESTYM filgrastim-aafi SYRINGE 300 mcg/0.5 mL N Y  
00069029110 NIVESTYM filgrastim-aafi SYRINGE 300 mcg/0.5 mL N Y  
00069029201 NIVESTYM filgrastim-aafi SYRINGE 480 mcg/0.8 mL N Y  
00069029210 NIVESTYM filgrastim-aafi SYRINGE 480 mcg/0.8 mL N Y  
00069029301 NIVESTYM filgrastim-aafi VIAL 300 mcg/mL N Y  
00069029310 NIVESTYM filgrastim-aafi VIAL 300 mcg/mL N Y  
00069029401 NIVESTYM filgrastim-aafi VIAL 480 mcg/1.6 mL N Y  
00069029410 NIVESTYM filgrastim-aafi VIAL 480 mcg/1.6 mL N Y  
70121156801 RELEUKO filgrastim-ayow SYRINGE 300 mcg/0.5 mL N Y  
70121156807 RELEUKO filgrastim-ayow SYRINGE 300 mcg/0.5 mL N Y  
70121157001 RELEUKO filgrastim-ayow SYRINGE 480 mcg/0.8 mL N Y  
70121157007 RELEUKO filgrastim-ayow SYRINGE 480 mcg/0.8 mL N Y  
70121157101 RELEUKO filgrastim-ayow VIAL 480 mcg/1.6 mL N Y  
61314031801 ZARXIO filgrastim-sndz SYRINGE 300 mcg/0.5 mL N Y  
61314031805 ZARXIO filgrastim-sndz SYRINGE 300 mcg/0.5 mL N Y  
61314031810 ZARXIO filgrastim-sndz SYRINGE 300 mcg/0.5 mL N Y  
61314032601 ZARXIO filgrastim-sndz SYRINGE 480 mcg/0.8 mL N Y  
61314032605 ZARXIO filgrastim-sndz SYRINGE 480 mcg/0.8 mL N Y  
61314032610 ZARXIO filgrastim-sndz SYRINGE 480 mcg/0.8 mL N Y  
55513019201 NEULASTA ONPRO pegfilgrastim SYR W/ INJ 6 mg/0.6 mL deliverable N Y  
55513019001 NEULASTA pegfilgrastim SYRINGE 6 mg/0.6 mL N Y  
00069032401 NYVEPRIA pegfilgrastim-apgf SYRINGE 6 mg/0.6 mL N Y  
61314086601 ZIEXTENZO pegfilgrastim-bmez SYRINGE 6 mg/0.6 mL N Y  
61314086602 ZIEXTENZO pegfilgrastim-bmez SYRINGE 6 mg/0.6 mL N Y  
70114012001 UDENYCA AUTOINJECTOR pegfilgrastim-cbqv AUTO INJCT 6 mg/0.6 mL N Y  
70114013001 UDENYCA ONBODY pegfilgrastim-cbqv SYR W/ INJ 6 mg/0.6 mL deliverable N Y  
70114010101 UDENYCA pegfilgrastim-cbqv SYRINGE 6 mg/0.6 mL N Y  
65219037110 STIMUFEND pegfilgrastim-fpgk SYRINGE 6 mg/0.6 mL N Y  
67457083306 FULPHILA pegfilgrastim-jmdb SYRINGE 6 mg/0.6 mL N Y  
83257000541 FULPHILA pegfilgrastim-jmdb SYRINGE 6 mg/0.6 mL N Y  
70121162701 FYLNETRA pegfilgrastim-pbbk SYRINGE 6 mg/0.6 mL N Y  
71837584301 LEUKINE sargramostim VIAL 250 mcg Y Y  
71837584305 LEUKINE sargramostim VIAL 250 mcg Y Y  
63459091001 GRANIX tbo-filgrastim SYRINGE 300 mcg/0.5 mL N Y  
63459091011 GRANIX tbo-filgrastim SYRINGE 300 mcg/0.5 mL N Y  
63459091012 GRANIX tbo-filgrastim SYRINGE 300 mcg/0.5 mL N Y  
63459091015 GRANIX tbo-filgrastim SYRINGE 300 mcg/0.5 mL N Y  
63459091017 GRANIX tbo-filgrastim SYRINGE 300 mcg/0.5 mL N Y  
63459091018 GRANIX tbo-filgrastim SYRINGE 300 mcg/0.5 mL N Y  
63459091036 GRANIX tbo-filgrastim SYRINGE 300 mcg/0.5 mL N Y  
63459091201 GRANIX tbo-filgrastim SYRINGE 480 mcg/0.8 mL N Y  
63459091211 GRANIX tbo-filgrastim SYRINGE 480 mcg/0.8 mL N Y  
63459091212 GRANIX tbo-filgrastim SYRINGE 480 mcg/0.8 mL N Y  
63459091215 GRANIX tbo-filgrastim SYRINGE 480 mcg/0.8 mL N Y  
63459091217 GRANIX tbo-filgrastim SYRINGE 480 mcg/0.8 mL N Y  
63459091218 GRANIX tbo-filgrastim SYRINGE 480 mcg/0.8 mL N Y  
63459091236 GRANIX tbo-filgrastim SYRINGE 480 mcg/0.8 mL N Y  
63459091853 GRANIX tbo-filgrastim VIAL 300 mcg/mL N Y  
63459091859 GRANIX tbo-filgrastim VIAL 300 mcg/mL N Y  
63459092053 GRANIX tbo-filgrastim VIAL 480 mcg/1.6 mL N Y  
63459092059 GRANIX tbo-filgrastim VIAL 480 mcg/1.6 mL N Y  
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