Interstitial Lung Disease

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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 Carveout
‐ Bill FFS		 Current Drug Use Criteria
00597014360 OFEV nintedanib esylate CAPSULE 100 mg N Y N Pharmacy PA
00597014560 OFEV nintedanib esylate CAPSULE 150 mg N Y N Pharmacy PA
50242012101 ESBRIET pirfenidone CAPSULE 267 mg N Y N Pharmacy PA
00781215832 PIRFENIDONE pirfenidone CAPSULE 267 mg N Y N Pharmacy PA
42385092329 PIRFENIDONE pirfenidone CAPSULE 267 mg N Y N Pharmacy PA
60219164207 PIRFENIDONE pirfenidone CAPSULE 267 mg N Y N Pharmacy PA
69097094093 PIRFENIDONE pirfenidone CAPSULE 267 mg N Y N Pharmacy PA
76282071527 PIRFENIDONE pirfenidone CAPSULE 267 mg N Y N Pharmacy PA
50242012206 ESBRIET pirfenidone TABLET 267 mg N Y N Pharmacy PA
00480361087 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
00781808532 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
00904739753 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
00904739789 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
31722087227 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
31722087290 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
42385092490 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
42385092499 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
42571033539 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
60219164008 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
60219164009 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
60505468107 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
62332047964 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
62332047990 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
69097098793 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
70954086930 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
72205018126 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
72205018130 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
72205018190 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
72603025801 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
72603025803 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
76282071727 PIRFENIDONE pirfenidone TABLET 267 mg N Y N Pharmacy PA
42385092590 PIRFENIDONE pirfenidone TABLET 534 mg N Y N Pharmacy PA
50242012301 ESBRIET pirfenidone TABLET 801 mg N Y N Pharmacy PA
00480361198 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
00781808692 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
00904739889 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
31722087390 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
42385092690 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
42571033690 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
60219164109 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
60505468209 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
62332048090 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
69097098805 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
70954087010 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
72205018230 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
72205018290 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
72603025901 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
76282071690 PIRFENIDONE pirfenidone TABLET 801 mg N Y N Pharmacy PA
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