Hereditary Angioedema

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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
72769010201 ORLADEYO berotralstat hydrochloride CAPSULE 110 mg N Y N Pharmacy PA
72769010101 ORLADEYO berotralstat hydrochloride CAPSULE 150 mg N Y N Pharmacy PA
63833082502 BERINERT C1 esterase inhibitor KIT 500 unit (10 mL) Y Y N Pharmacy PA
63833082802 HAEGARDA C1 esterase inhibitor VIAL 2,000 unit Y Y N Pharmacy PA
63833082902 HAEGARDA C1 esterase inhibitor VIAL 3,000 unit Y Y N Pharmacy PA
63833083501 BERINERT C1 esterase inhibitor VIAL 500 unit (10 mL) Y Y N Pharmacy PA
42227008101 CINRYZE C1 esterase inhibitor VIAL 500 unit (5 mL) N Y N Pharmacy PA
42227008301 CINRYZE C1 esterase inhibitor VIAL 500 unit (5 mL) N Y N Pharmacy PA
71274035001 RUCONEST C1 esterase inhibitor, recomb VIAL 2,100 unit N Y N Pharmacy PA
71274035002 RUCONEST C1 esterase inhibitor, recomb VIAL 2,100 unit N Y N Pharmacy PA
71860010301 DAWNZERA donidalorsen sodium AUTO INJCT 80 mg/0.8 mL N Y N Pharmacy PA
47783010101 KALBITOR ecallantide VIAL 10 mg/mL (1 mL) N Y N Pharmacy PA
54092070202 FIRAZYR icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
54092070203 FIRAZYR icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
00093306619 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
00093306634 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
00093306693 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
24201020701 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
54092013501 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
54092013502 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
55150035101 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
55150035103 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
60505621401 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
62332065403 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
62332065409 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
63323057401 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
63323057486 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
63323057493 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
69097066434 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
69097066468 ICATIBANT icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
70709001301 SAJAZIR icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
70709001303 SAJAZIR icatibant acetate SYRINGE 30 mg/3 mL N Y N Pharmacy PA
47783064501 TAKHZYRO lanadelumab-flyo SYRINGE 150 mg/mL N Y N Pharmacy PA
47783064601 TAKHZYRO lanadelumab-flyo SYRINGE 300 mg/2 mL (150 mg/mL) N Y N Pharmacy PA
47783064401 TAKHZYRO lanadelumab-flyo VIAL 300 mg/2 mL (150 mg/mL) N Y N Pharmacy PA
82928030001 EKTERLY sebetralstat TABLET 300 mg N Y N Pharmacy PA
82928030004 EKTERLY sebetralstat TABLET 300 mg N Y N Pharmacy PA
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