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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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 82154045101 | PEGASYS | peginterferon alfa-2a | SYRINGE | 180 mcg/0.5 mL | Y | Y | N | |
| 82154045104 | PEGASYS | peginterferon alfa-2a | SYRINGE | 180 mcg/0.5 mL | Y | Y | N | |
| 82154044901 | PEGASYS | peginterferon alfa-2a | VIAL | 180 mcg/mL | Y | Y | N | |
| 65862029018 | RIBAVIRIN | ribavirin | CAPSULE | 200 mg | Y | Y | N | |
| 65862029042 | RIBAVIRIN | ribavirin | CAPSULE | 200 mg | Y | Y | N | |
| 65862029056 | RIBAVIRIN | ribavirin | CAPSULE | 200 mg | Y | Y | N | |
| 65862029070 | RIBAVIRIN | ribavirin | CAPSULE | 200 mg | Y | Y | N | |
| 65862029084 | RIBAVIRIN | ribavirin | CAPSULE | 200 mg | Y | Y | N | |
| 68382026010 | RIBAVIRIN | ribavirin | CAPSULE | 200 mg | Y | Y | N | |
| 68382026028 | RIBAVIRIN | ribavirin | CAPSULE | 200 mg | Y | Y | N | |
| 65862020768 | RIBAVIRIN | ribavirin | TABLET | 200 mg | Y | Y | N | |
| 00085124101 | REBETRON 1200 | ribavirin/interferon alfa-2b,r | KIT | 1,200 mg (6 x 200 mg caps)-3 million unit/0.5 mL | Y | N | ||
| 00085124103 | REBETRON 600 | ribavirin/interferon alfa-2b,r | KIT | 600 mg (3 x 200 mg caps)-3 million unit/0.5 mL | Y | N |