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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 |
|---|---|---|---|---|---|---|---|---|
| 00074709530 | QULIPTA | atogepant | TABLET | 10 mg | N | Y | N | Pharmacy PA |
| 00074709630 | QULIPTA | atogepant | TABLET | 30 mg | N | Y | N | Pharmacy PA |
| 00074709404 | QULIPTA | atogepant | TABLET | 60 mg | N | Y | N | Pharmacy PA |
| 00074709430 | QULIPTA | atogepant | TABLET | 60 mg | N | Y | N | Pharmacy PA |
| 64896050901 | BREKIYA | dihydroergotamine mesylate | AUTO INJCT | 1 mg/mL | Y | N | Pharmacy PA | |
| 64896050902 | BREKIYA | dihydroergotamine mesylate | AUTO INJCT | 1 mg/mL | Y | N | Pharmacy PA | |
| 67386013051 | VYEPTI | eptinezumab-jjmr | VIAL | 100 mg/mL | N | Y | N | Pharmacy PA |
| 55513084301 | AIMOVIG AUTOINJECTOR | erenumab-aooe | AUTO INJCT | 140 mg/mL | Y | Y | N | Pharmacy PA |
| 55513084101 | AIMOVIG AUTOINJECTOR | erenumab-aooe | AUTO INJCT | 70 mg/mL | Y | Y | N | Pharmacy PA |
| 51759020210 | AJOVY AUTOINJECTOR | fremanezumab-vfrm | AUTO INJCT | 225 mg/1.5 mL | Y | Y | N | Pharmacy PA |
| 51759020211 | AJOVY AUTOINJECTOR | fremanezumab-vfrm | AUTO INJCT | 225 mg/1.5 mL | Y | Y | N | Pharmacy PA |
| 51759020222 | AJOVY AUTOINJECTOR | fremanezumab-vfrm | AUTO INJCT | 225 mg/1.5 mL | Y | Y | N | Pharmacy PA |
| 51759020410 | AJOVY SYRINGE | fremanezumab-vfrm | SYRINGE | 225 mg/1.5 mL | Y | Y | N | Pharmacy PA |
| 51759020411 | AJOVY SYRINGE | fremanezumab-vfrm | SYRINGE | 225 mg/1.5 mL | Y | Y | N | Pharmacy PA |
| 00002143601 | EMGALITY PEN | galcanezumab-gnlm | PEN INJCTR | 120 mg/mL | N | Y | N | Pharmacy PA |
| 00002143611 | EMGALITY PEN | galcanezumab-gnlm | PEN INJCTR | 120 mg/mL | N | Y | N | Pharmacy PA |
| 00002237701 | EMGALITY SYRINGE | galcanezumab-gnlm | SYRINGE | 120 mg/mL | N | Y | N | Pharmacy PA |
| 00002237711 | EMGALITY SYRINGE | galcanezumab-gnlm | SYRINGE | 120 mg/mL | N | Y | N | Pharmacy PA |
| 00002311501 | EMGALITY SYRINGE | galcanezumab-gnlm | SYRINGE | 300 mg/3 mL (100 mg/mL x 3) | N | Y | N | Pharmacy PA |
| 00002311509 | EMGALITY SYRINGE | galcanezumab-gnlm | SYRINGE | 300 mg/3 mL (100 mg/mL x 3) | N | Y | N | Pharmacy PA |
| 72618300002 | NURTEC ODT | rimegepant sulfate | TAB RAPDIS | 75 mg | N | Y | N | Pharmacy PA |
| 72618300101 | NURTEC ODT | rimegepant sulfate | TAB RAPDIS | 75 mg | N | Y | N | Pharmacy PA |
| 72618300102 | NURTEC ODT | rimegepant sulfate | TAB RAPDIS | 75 mg | N | Y | N | Pharmacy PA |
| 00023650101 | UBRELVY | ubrogepant | TABLET | 100 mg | Y | Y | N | Pharmacy PA |
| 00023650102 | UBRELVY | ubrogepant | TABLET | 100 mg | Y | Y | N | Pharmacy PA |
| 00023650110 | UBRELVY | ubrogepant | TABLET | 100 mg | Y | Y | N | Pharmacy PA |
| 00023650116 | UBRELVY | ubrogepant | TABLET | 100 mg | Y | Y | N | Pharmacy PA |
| 00023649802 | UBRELVY | ubrogepant | TABLET | 50 mg | Y | Y | N | Pharmacy PA |
| 00023649810 | UBRELVY | ubrogepant | TABLET | 50 mg | Y | Y | N | Pharmacy PA |
| 00069350001 | ZAVZPRET | zavegepant HCl | SPRAY | 10 mg/actuation | N | Y | N | Pharmacy PA |
| 00069350002 | ZAVZPRET | zavegepant HCl | SPRAY | 10 mg/actuation | N | Y | N | Pharmacy PA |