Anaphylaxis Rescue
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 60842002101 | AUVI-Q | epinephrine | AUTO INJCT | 0.1 mg/0.1 mL | Y | Y | N | |
| 60842002102 | AUVI-Q | epinephrine | AUTO INJCT | 0.1 mg/0.1 mL | Y | Y | N | |
| 60842002201 | AUVI-Q | epinephrine | AUTO INJCT | 0.15 mg/0.15 mL | Y | Y | N | |
| 60842002202 | AUVI-Q | epinephrine | AUTO INJCT | 0.15 mg/0.15 mL | Y | Y | N | |
| 00115169530 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.15 mg/0.15 mL | Y | Y | N | |
| 00115169549 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.15 mg/0.15 mL | Y | Y | N | |
| 00093598519 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.15 mg/0.3 mL | Y | Y | N | |
| 00093598527 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.15 mg/0.3 mL | Y | Y | N | |
| 49502010101 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.15 mg/0.3 mL | Y | Y | N | |
| 49502010102 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.15 mg/0.3 mL | Y | Y | N | |
| 49502050101 | EPIPEN JR | epinephrine | AUTO INJCT | 0.15 mg/0.3 mL | Y | Y | N | |
| 49502050102 | EPIPEN JR 2-PAK | epinephrine | AUTO INJCT | 0.15 mg/0.3 mL | Y | Y | N | |
| 60842002301 | AUVI-Q | epinephrine | AUTO INJCT | 0.3 mg/0.3 mL | Y | Y | N | |
| 60842002302 | AUVI-Q | epinephrine | AUTO INJCT | 0.3 mg/0.3 mL | Y | Y | N | |
| 00093598619 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.3 mg/0.3 mL | Y | Y | N | |
| 00093598627 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.3 mg/0.3 mL | Y | Y | N | |
| 00115169430 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.3 mg/0.3 mL | Y | Y | N | |
| 00115169449 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.3 mg/0.3 mL | Y | Y | N | |
| 49502010201 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.3 mg/0.3 mL | Y | Y | N | |
| 49502010202 | EPINEPHRINE | epinephrine | AUTO INJCT | 0.3 mg/0.3 mL | Y | Y | N | |
| 49502050001 | EPIPEN | epinephrine | AUTO INJCT | 0.3 mg/0.3 mL | Y | Y | N | |
| 49502050002 | EPIPEN 2-PAK | epinephrine | AUTO INJCT | 0.3 mg/0.3 mL | Y | Y | N | |
| 82580001002 | NEFFY | epinephrine | SPRAY | 1 mg/spray (0.1 mL) | N | Y | N | |
| 82580002002 | NEFFY | epinephrine | SPRAY | 2 mg/spray (0.1 mL) | N | Y | N |