Lysosomal Storage Disorders
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 | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 58468004001 | FABRAZYME | agalsidase beta | VIAL | 35 mg | N | Y | PA Document |
| 58468004101 | FABRAZYME | agalsidase beta | VIAL | 5 mg | N | Y | PA Document |
| 58468016001 | LUMIZYME | alglucosidase alfa | VIAL | 50 mg | N | Y | PA Document |
| 58468042601 | NEXVIAZYME | avalglucosidase alfa-ngpt | VIAL | 100 mg | N | Y | PA Document |
| 71904020001 | POMBILITI | cipaglucosidase alfa-atga | VIAL | 105 mg | N | Y | PA Document |
| 71904020002 | POMBILITI | cipaglucosidase alfa-atga | VIAL | 105 mg | N | Y | PA Document |
| 71904020003 | POMBILITI | cipaglucosidase alfa-atga | VIAL | 105 mg | N | Y | PA Document |
| 58468022001 | CERDELGA | eliglustat tartrate | CAPSULE | 84 mg | N | Y | PA Document |
| 68135010001 | VIMIZIM | elosulfase alfa | VIAL | 5 mg/5 mL (1 mg/mL) | Y | ||
| 68135002001 | NAGLAZYME | galsulfase | VIAL | 5 mg/5 mL | Y | ||
| 54092070001 | ELAPRASE | idursulfase | VIAL | 6 mg/3 mL | Y | ||
| 58468466301 | CEREZYME | imiglucerase | VIAL | 400 unit | N | Y | PA Document |
| 58468007001 | ALDURAZYME | laronidase | VIAL | 2.9 mg/5 mL | Y | ||
| 71904010001 | GALAFOLD | migalastat HCl | CAPSULE | 123 mg | N | Y | PA Document |
| 10148020115 | MIGLUSTAT | miglustat | CAPSULE | 100 mg | N | Y | PA Document |
| 10148020190 | MIGLUSTAT | miglustat | CAPSULE | 100 mg | N | Y | PA Document |
| 42799070815 | MIGLUSTAT | miglustat | CAPSULE | 100 mg | N | Y | PA Document |
| 43975031008 | MIGLUSTAT | miglustat | CAPSULE | 100 mg | N | Y | PA Document |
| 43975031083 | MIGLUSTAT | miglustat | CAPSULE | 100 mg | N | Y | PA Document |
| 70710203904 | MIGLUSTAT | miglustat | CAPSULE | 100 mg | N | Y | PA Document |
| 70710203908 | MIGLUSTAT | miglustat | CAPSULE | 100 mg | N | Y | PA Document |
| 42799070915 | YARGESA | miglustat | CAPSULE | 100 mg | N | Y | PA Document |
| 66215020115 | ZAVESCA | miglustat | CAPSULE | 100 mg | N | Y | PA Document |
| 66215020190 | ZAVESCA | miglustat | CAPSULE | 100 mg | N | Y | PA Document |
| 71904030001 | OPFOLDA | miglustat | CAPSULE | 65 mg | N | Y | PA Document |
| 71904030002 | OPFOLDA | miglustat | CAPSULE | 65 mg | N | Y | PA Document |
| 71904030003 | OPFOLDA | miglustat | CAPSULE | 65 mg | N | Y | PA Document |
| 10122016001 | ELFABRIO | pegunigalsidase alfa-iwxj | VIAL | 20 mg/10 mL (2 mg/mL) | N | Y | PA Document |
| 10122016002 | ELFABRIO | pegunigalsidase alfa-iwxj | VIAL | 20 mg/10 mL (2 mg/mL) | N | Y | PA Document |
| 10122016005 | ELFABRIO | pegunigalsidase alfa-iwxj | VIAL | 20 mg/10 mL (2 mg/mL) | N | Y | PA Document |
| 10122016010 | ELFABRIO | pegunigalsidase alfa-iwxj | VIAL | 20 mg/10 mL (2 mg/mL) | N | Y | PA Document |
| 10122016502 | ELFABRIO | pegunigalsidase alfa-iwxj | VIAL | 5 mg/2.5 mL (2 mg/mL) | N | Y | PA Document |
| 25682000701 | KANUMA | sebelipase alfa | VIAL | 20 mg/10 mL (2 mg/mL) | Y | ||
| 00069010601 | ELELYSO | taliglucerase alfa | VIAL | 200 unit | Y | Y | PA Document |
| 54092070104 | VPRIV | velaglucerase alfa | VIAL | 400 unit | N | Y | PA Document |
| 69794000101 | MEPSEVII | vestronidase alfa-vjbk | VIAL | 10 mg/5 mL (2 mg/mL) | Y |