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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 |
|---|---|---|---|---|---|---|---|---|
| 00006307401 | ZEPATIER | elbasvir/grazoprevir | TABLET | 50 mg-100 mg | N | Y | N | Quantity Limit |
| 00006307402 | ZEPATIER | elbasvir/grazoprevir | TABLET | 50 mg-100 mg | N | Y | N | Quantity Limit |
| 00074260028 | MAVYRET | glecaprevir/pibrentasvir | PELET PACK | 50 mg-20 mg | N | Y | N | Quantity Limit |
| 00074262501 | MAVYRET | glecaprevir/pibrentasvir | TABLET | 100 mg-40 mg | Y | Y | N | Quantity Limit |
| 00074262504 | MAVYRET | glecaprevir/pibrentasvir | TABLET | 100 mg-40 mg | Y | Y | N | Quantity Limit |
| 00074262528 | MAVYRET | glecaprevir/pibrentasvir | TABLET | 100 mg-40 mg | Y | Y | N | Quantity Limit |
| 00074262584 | MAVYRET | glecaprevir/pibrentasvir | TABLET | 100 mg-40 mg | Y | Y | N | Quantity Limit |
| 61958180501 | HARVONI | ledipasvir/sofosbuvir | PELET PACK | 33.75 mg-150 mg | N | Y | N | Quantity Limit |
| 61958180502 | HARVONI | ledipasvir/sofosbuvir | PELET PACK | 33.75 mg-150 mg | N | Y | N | Quantity Limit |
| 61958180401 | HARVONI | ledipasvir/sofosbuvir | PELET PACK | 45 mg-200 mg | N | Y | N | Quantity Limit |
| 61958180402 | HARVONI | ledipasvir/sofosbuvir | PELET PACK | 45 mg-200 mg | N | Y | N | Quantity Limit |
| 61958180301 | HARVONI | ledipasvir/sofosbuvir | TABLET | 45 mg-200 mg | N | Y | N | Quantity Limit |
| 61958180101 | HARVONI | ledipasvir/sofosbuvir | TABLET | 90 mg-400 mg | N | Y | N | Quantity Limit |
| 72626260101 | LEDIPASVIR-SOFOSBUVIR | ledipasvir/sofosbuvir | TABLET | 90 mg-400 mg | N | Y | N | Quantity Limit |
| 61958150401 | SOVALDI | sofosbuvir | PELET PACK | 150 mg | N | Y | N | Quantity Limit |
| 61958150402 | SOVALDI | sofosbuvir | PELET PACK | 150 mg | N | Y | N | Quantity Limit |
| 61958150501 | SOVALDI | sofosbuvir | PELET PACK | 200 mg | N | Y | N | Quantity Limit |
| 61958150502 | SOVALDI | sofosbuvir | PELET PACK | 200 mg | N | Y | N | Quantity Limit |
| 61958150301 | SOVALDI | sofosbuvir | TABLET | 200 mg | N | Y | N | Quantity Limit |
| 61958150101 | SOVALDI | sofosbuvir | TABLET | 400 mg | N | Y | N | Quantity Limit |
| 61958240101 | VOSEVI | sofosbuvir/velpatas/voxilaprev | TABLET | 400 mg-100 mg-100 mg | N | Y | N | Quantity Limit |
| 61958220501 | EPCLUSA | sofosbuvir/velpatasvir | PELET PACK | 150 mg-37.5 mg | N | Y | N | Quantity Limit |
| 61958220502 | EPCLUSA | sofosbuvir/velpatasvir | PELET PACK | 150 mg-37.5 mg | N | Y | N | Quantity Limit |
| 61958220401 | EPCLUSA | sofosbuvir/velpatasvir | PELET PACK | 200 mg-50 mg | N | Y | N | Quantity Limit |
| 61958220402 | EPCLUSA | sofosbuvir/velpatasvir | PELET PACK | 200 mg-50 mg | N | Y | N | Quantity Limit |
| 61958220301 | EPCLUSA | sofosbuvir/velpatasvir | TABLET | 200 mg-50 mg | N | Y | N | Quantity Limit |
| 61958220101 | EPCLUSA | sofosbuvir/velpatasvir | TABLET | 400 mg-100 mg | N | Y | N | Quantity Limit |
| 72626270101 | SOFOSBUVIR-VELPATASVIR | sofosbuvir/velpatasvir | TABLET | 400 mg-100 mg | Y | Y | N | Quantity Limit |