Multiple Sclerosis

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PDL Reference Documents

Drug Use Review 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 Carveout
‐ Bill FFS		 Current Drug Use Criteria
58468020001 LEMTRADA alemtuzumab VIAL 12 mg/1.2 mL N Y N Pharmacy PA
44087400000 MAVENCLAD cladribine TABLET 10 mg N Y N Pharmacy PA
44087400004 MAVENCLAD cladribine TABLET 10 mg N Y N Pharmacy PA
44087400005 MAVENCLAD cladribine TABLET 10 mg N Y N Pharmacy PA
44087400006 MAVENCLAD cladribine TABLET 10 mg N Y N Pharmacy PA
44087400007 MAVENCLAD cladribine TABLET 10 mg N Y N Pharmacy PA
44087400008 MAVENCLAD cladribine TABLET 10 mg N Y N Pharmacy PA
44087400009 MAVENCLAD cladribine TABLET 10 mg N Y N Pharmacy PA
10144042760 AMPYRA dalfampridine TAB ER 12H 10 mg N Y N Pharmacy PA
00591253360 DALFAMPRIDINE ER dalfampridine TAB ER 12H 10 mg N Y N Pharmacy PA
16729029212 DALFAMPRIDINE ER dalfampridine TAB ER 12H 10 mg N Y N Pharmacy PA
42571027560 DALFAMPRIDINE ER dalfampridine TAB ER 12H 10 mg N Y N Pharmacy PA
62756042986 DALFAMPRIDINE ER dalfampridine TAB ER 12H 10 mg N Y N Pharmacy PA
67877044460 DALFAMPRIDINE ER dalfampridine TAB ER 12H 10 mg N Y N Pharmacy PA
82249070260 DALFAMPRIDINE ER dalfampridine TAB ER 12H 10 mg N Y N Pharmacy PA
00378039614 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
16729041604 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
24979012721 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
31722065731 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
33342034994 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
43547002414 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
43598042952 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
59651008314 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
67877055514 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
67877055532 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
68180077614 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
68180077665 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
69097032228 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
69097032289 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
69238131804 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
70512085214 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
82249074514 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
64406000501 TECFIDERA dimethyl fumarate CAPSULE DR 120 mg N Y N Pharmacy PA
31722068060 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg (14)-240 mg (46) N Y N Pharmacy PA
67877055739 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg (14)-240 mg (46) N Y N Pharmacy PA
68180077813 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg (14)-240 mg (46) N Y N Pharmacy PA
69097055203 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg (14)-240 mg (46) N Y N Pharmacy PA
69238162603 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 120 mg (14)-240 mg (46) N Y N Pharmacy PA
64406000703 TECFIDERA dimethyl fumarate CAPSULE DR 120 mg (14)-240 mg (46) N Y N Pharmacy PA
00378039991 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
16729041712 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
24979012804 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
31722065832 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
33342035009 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
43547002506 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
43598043060 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
59651008460 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
67877055623 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
67877055660 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
68180077707 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
68180077748 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
69097032303 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
69097032388 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
69238131906 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
70512085360 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
82009013860 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
82249074760 DIMETHYL FUMARATE dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
64406000602 TECFIDERA dimethyl fumarate CAPSULE DR 240 mg N Y N Pharmacy PA
64406002003 VUMERITY diroximel fumarate CAPSULE DR 231 mg N Y N Pharmacy PA
00078096589 GILENYA fingolimod HCl CAPSULE 0.25 mg N Y N Pharmacy PA
00480782056 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
16729034210 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
31722088930 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
43598028530 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
60505433203 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
62756006483 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
64980044903 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
65862095230 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
67877047630 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
68382091206 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
68462016630 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
82009014330 FINGOLIMOD fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
00078060715 GILENYA fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
00078060789 GILENYA fingolimod HCl CAPSULE 0.5 mg N Y N Pharmacy PA
70709006230 TASCENSO ODT fingolimod lauryl sulfate TAB RAPDIS 0.25 mg N Y N Pharmacy PA
70709006530 TASCENSO ODT fingolimod lauryl sulfate TAB RAPDIS 0.5 mg N Y N Pharmacy PA
68546031730 COPAXONE glatiramer acetate SYRINGE 20 mg/mL Y Y N Pharmacy PA
00378696032 GLATIRAMER ACETATE glatiramer acetate SYRINGE 20 mg/mL N Y N Pharmacy PA
00378696093 GLATIRAMER ACETATE glatiramer acetate SYRINGE 20 mg/mL N Y N Pharmacy PA
47335099001 GLATIRAMER ACETATE glatiramer acetate SYRINGE 20 mg/mL N Y N Pharmacy PA
47335099002 GLATIRAMER ACETATE glatiramer acetate SYRINGE 20 mg/mL N Y N Pharmacy PA
00781323434 GLATOPA glatiramer acetate SYRINGE 20 mg/mL N Y N Pharmacy PA
00781323471 GLATOPA glatiramer acetate SYRINGE 20 mg/mL N Y N Pharmacy PA
68546032506 COPAXONE glatiramer acetate SYRINGE 40 mg/mL N Y N Pharmacy PA
68546032512 COPAXONE glatiramer acetate SYRINGE 40 mg/mL N Y N Pharmacy PA
00378696112 GLATIRAMER ACETATE glatiramer acetate SYRINGE 40 mg/mL N Y N Pharmacy PA
00378696132 GLATIRAMER ACETATE glatiramer acetate SYRINGE 40 mg/mL N Y N Pharmacy PA
47335099101 GLATIRAMER ACETATE glatiramer acetate SYRINGE 40 mg/mL N Y N Pharmacy PA
47335099102 GLATIRAMER ACETATE glatiramer acetate SYRINGE 40 mg/mL N Y N Pharmacy PA
00781325071 GLATOPA glatiramer acetate SYRINGE 40 mg/mL N Y N Pharmacy PA
00781325089 GLATOPA glatiramer acetate SYRINGE 40 mg/mL N Y N Pharmacy PA
59627033304 AVONEX PEN (4 PACK) interferon beta-1a PEN IJ KIT 30 mcg/0.5 mL Y Y N  
59627000206 AVONEX interferon beta-1a SYRINGE 30 mcg/0.5 mL Y Y N  
59627022205 AVONEX (4 PACK) interferon beta-1a SYRINGEKIT 30 mcg/0.5 mL Y Y N  
44087332201 REBIF REBIDOSE interferon beta-1a/albumin PEN INJCTR 22 mcg/0.5 mL Y Y N  
44087332209 REBIF REBIDOSE interferon beta-1a/albumin PEN INJCTR 22 mcg/0.5 mL Y Y N  
44087334401 REBIF REBIDOSE interferon beta-1a/albumin PEN INJCTR 44 mcg/0.5 mL Y Y N  
44087334409 REBIF REBIDOSE interferon beta-1a/albumin PEN INJCTR 44 mcg/0.5 mL Y Y N  
44087018801 REBIF REBIDOSE interferon beta-1a/albumin PEN INJCTR 8.8 mcg/0.2 mL (6) - 22 mcg/0.5 mL (6) Y Y N  
44087002203 REBIF interferon beta-1a/albumin SYRINGE 22 mcg/0.5 mL Y Y N  
44087002209 REBIF interferon beta-1a/albumin SYRINGE 22 mcg/0.5 mL Y Y N  
44087004403 REBIF interferon beta-1a/albumin SYRINGE 44 mcg/0.5 mL Y Y N  
44087004409 REBIF interferon beta-1a/albumin SYRINGE 44 mcg/0.5 mL Y Y N  
44087882201 REBIF interferon beta-1a/albumin SYRINGE 8.8 mcg/0.2 mL (6) - 22 mcg/0.5 mL (6) Y Y N  
50419052309 BETASERON interferon beta-1b KIT 0.3 mg Y Y N  
50419052401 BETASERON interferon beta-1b KIT 0.3 mg Y Y N  
50419052435 BETASERON interferon beta-1b KIT 0.3 mg Y Y N  
50419052201 BETASERON interferon beta-1b VIAL 0.3 mg N Y N Pharmacy PA
69387000101 BAFIERTAM monomethyl fumarate CAPSULE DR 95 mg N Y N Pharmacy PA
61314054394 TYRUKO natalizumab-sztn VIAL 300 mg/15 mL N Y N Pharmacy PA
50242015001 OCREVUS ocrelizumab VIAL 300 mg/10 mL N Y N Pharmacy PA
50242055401 OCREVUS ZUNOVO ocrelizumab-hyaluronidase-ocsq VIAL 920 mg-23,000 unit/23 mL N Y N Pharmacy PA
00078100768 KESIMPTA PEN ofatumumab PEN INJCTR 20 mg/0.4 mL N Y N Pharmacy PA
00078100798 KESIMPTA PEN ofatumumab PEN INJCTR 20 mg/0.4 mL N Y N Pharmacy PA
59572081007 ZEPOSIA ozanimod hydrochloride CAP DS PK 0.23 mg (4)-0.46 mg (3) N Y N Pharmacy PA
59572089007 ZEPOSIA ozanimod hydrochloride CAP DS PK 0.23 mg (4)-0.46 mg (3) N Y N Pharmacy PA
59572089028 ZEPOSIA ozanimod hydrochloride CAP DS PK 0.23 mg (4)-0.46 mg (3)-0.92 mg (21) N Y N Pharmacy PA
59572082030 ZEPOSIA ozanimod hydrochloride CAPSULE 0.92 mg N Y N Pharmacy PA
59572089021 ZEPOSIA ozanimod hydrochloride CAPSULE 0.92 mg N Y N Pharmacy PA
64406001101 PLEGRIDY PEN peginterferon beta-1a PEN INJCTR 125 mcg/0.5 mL Y Y N  
64406001102 PLEGRIDY PEN peginterferon beta-1a PEN INJCTR 125 mcg/0.5 mL Y Y N  
64406001201 PLEGRIDY PEN peginterferon beta-1a PEN INJCTR 63 mcg/0.5 mL (1)-94 mcg/0.5 mL (1) Y Y N  
64406001501 PLEGRIDY peginterferon beta-1a SYRINGE 125 mcg/0.5 mL Y Y N  
64406001502 PLEGRIDY peginterferon beta-1a SYRINGE 125 mcg/0.5 mL Y Y N  
64406001701 PLEGRIDY peginterferon beta-1a SYRINGE 125 mcg/0.5 mL Y Y N  
64406001702 PLEGRIDY peginterferon beta-1a SYRINGE 125 mcg/0.5 mL Y Y N  
64406001601 PLEGRIDY peginterferon beta-1a SYRINGE 63 mcg/0.5 mL (1)-94 mcg/0.5 mL (1) Y Y N  
43068061009 PONVORY ponesimod TAB DS PK 2 mg(2)-3 mg(2)-4 mg(2)-5 mg-6 mg-7 mg-8 mg-9 mg-10 mg(3) N Y N Pharmacy PA
50458070714 PONVORY ponesimod TAB DS PK 2 mg(2)-3 mg(2)-4 mg(2)-5 mg-6 mg-7 mg-8 mg-9 mg-10 mg(3) N Y N Pharmacy PA
43068062001 PONVORY ponesimod TABLET 20 mg N Y N Pharmacy PA
50458072030 PONVORY ponesimod TABLET 20 mg N Y N Pharmacy PA
00078097912 MAYZENT siponimod TAB DS PK 0.25 mg (12 tabs) N Y N Pharmacy PA
00078097989 MAYZENT siponimod TAB DS PK 0.25 mg (7 tabs) N Y N Pharmacy PA
00078097950 MAYZENT siponimod TABLET 0.25 mg N Y N Pharmacy PA
00078101415 MAYZENT siponimod TABLET 1 mg N Y N Pharmacy PA
00078098615 MAYZENT siponimod TABLET 2 mg N Y N Pharmacy PA
00078098645 MAYZENT siponimod TABLET 2 mg N Y N Pharmacy PA
58468021004 AUBAGIO teriflunomide TABLET 14 mg N Y N Pharmacy PA
00480315656 TERIFLUNOMIDE teriflunomide TABLET 14 mg N Y N Pharmacy PA
31722024730 TERIFLUNOMIDE teriflunomide TABLET 14 mg N Y N Pharmacy PA
59651005530 TERIFLUNOMIDE teriflunomide TABLET 14 mg N Y N Pharmacy PA
60505447803 TERIFLUNOMIDE teriflunomide TABLET 14 mg N Y N Pharmacy PA
62332031430 TERIFLUNOMIDE teriflunomide TABLET 14 mg N Y N Pharmacy PA
68462042430 TERIFLUNOMIDE teriflunomide TABLET 14 mg N Y N Pharmacy PA
69238130406 TERIFLUNOMIDE teriflunomide TABLET 14 mg N Y N Pharmacy PA
70377001811 TERIFLUNOMIDE teriflunomide TABLET 14 mg N Y N Pharmacy PA
70512085128 TERIFLUNOMIDE teriflunomide TABLET 14 mg N Y N Pharmacy PA
70710111503 TERIFLUNOMIDE teriflunomide TABLET 14 mg N Y N Pharmacy PA
58468021104 AUBAGIO teriflunomide TABLET 7 mg N Y N Pharmacy PA
00480315756 TERIFLUNOMIDE teriflunomide TABLET 7 mg N Y N Pharmacy PA
00781574731 TERIFLUNOMIDE teriflunomide TABLET 7 mg N Y N Pharmacy PA
31722024630 TERIFLUNOMIDE teriflunomide TABLET 7 mg N Y N Pharmacy PA
59651005430 TERIFLUNOMIDE teriflunomide TABLET 7 mg N Y N Pharmacy PA
60505447703 TERIFLUNOMIDE teriflunomide TABLET 7 mg N Y N Pharmacy PA
62332031330 TERIFLUNOMIDE teriflunomide TABLET 7 mg N Y N Pharmacy PA
68462042330 TERIFLUNOMIDE teriflunomide TABLET 7 mg N Y N Pharmacy PA
69238130306 TERIFLUNOMIDE teriflunomide TABLET 7 mg N Y N Pharmacy PA
70377001711 TERIFLUNOMIDE teriflunomide TABLET 7 mg N Y N Pharmacy PA
70512085028 TERIFLUNOMIDE teriflunomide TABLET 7 mg N Y N Pharmacy PA
70710111403 TERIFLUNOMIDE teriflunomide TABLET 7 mg N Y N Pharmacy PA
73150015006 BRIUMVI ublituximab-xiiy VIAL 150 mg/6 mL (25 mg/mL) N Y N Pharmacy PA
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