Targeted Immune Modulators for Asthma and Atopic Dermatitis
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 |
|---|---|---|---|---|---|---|---|
| 00069033530 | CIBINQO | abrocitinib | TABLET | 100 mg | N | Y | PA Document |
| 00069043530 | CIBINQO | abrocitinib | TABLET | 200 mg | N | Y | PA Document |
| 00069023530 | CIBINQO | abrocitinib | TABLET | 50 mg | N | Y | PA Document |
| 00310183030 | FASENRA PEN | benralizumab | AUTO INJCT | 30 mg/mL | N | Y | PA Document |
| 00310183085 | FASENRA PEN | benralizumab | AUTO INJCT | 30 mg/mL | N | Y | PA Document |
| 00310174501 | FASENRA | benralizumab | SYRINGE | 10 mg/0.5 mL | N | Y | PA Document |
| 00310173030 | FASENRA | benralizumab | SYRINGE | 30 mg/mL | N | Y | PA Document |
| 00310173085 | FASENRA | benralizumab | SYRINGE | 30 mg/mL | N | Y | PA Document |
| 00024591900 | DUPIXENT PEN | dupilumab | PEN INJCTR | 200 mg/1.14 mL | N | Y | PA Document |
| 00024591901 | DUPIXENT PEN | dupilumab | PEN INJCTR | 200 mg/1.14 mL | N | Y | PA Document |
| 00024591902 | DUPIXENT PEN | dupilumab | PEN INJCTR | 200 mg/1.14 mL | N | Y | PA Document |
| 00024591920 | DUPIXENT PEN | dupilumab | PEN INJCTR | 200 mg/1.14 mL | N | Y | PA Document |
| 00024591500 | DUPIXENT PEN | dupilumab | PEN INJCTR | 300 mg/2 mL | N | Y | PA Document |
| 00024591501 | DUPIXENT PEN | dupilumab | PEN INJCTR | 300 mg/2 mL | N | Y | PA Document |
| 00024591502 | DUPIXENT PEN | dupilumab | PEN INJCTR | 300 mg/2 mL | N | Y | PA Document |
| 00024591520 | DUPIXENT PEN | dupilumab | PEN INJCTR | 300 mg/2 mL | N | Y | PA Document |
| 00024591100 | DUPIXENT SYRINGE | dupilumab | SYRINGE | 100 mg/0.67 mL | N | Y | PA Document |
| 00024591102 | DUPIXENT SYRINGE | dupilumab | SYRINGE | 100 mg/0.67 mL | N | Y | PA Document |
| 00024591800 | DUPIXENT SYRINGE | dupilumab | SYRINGE | 200 mg/1.14 mL | N | Y | PA Document |
| 00024591801 | DUPIXENT SYRINGE | dupilumab | SYRINGE | 200 mg/1.14 mL | N | Y | PA Document |
| 00024591802 | DUPIXENT SYRINGE | dupilumab | SYRINGE | 200 mg/1.14 mL | N | Y | PA Document |
| 00024591400 | DUPIXENT SYRINGE | dupilumab | SYRINGE | 300 mg/2 mL | N | Y | PA Document |
| 00024591401 | DUPIXENT SYRINGE | dupilumab | SYRINGE | 300 mg/2 mL | N | Y | PA Document |
| 00024591402 | DUPIXENT SYRINGE | dupilumab | SYRINGE | 300 mg/2 mL | N | Y | PA Document |
| 00002777201 | EBGLYSS PEN | lebrikizumab-lbkz | PEN INJCTR | 250 mg/2 mL | N | Y | PA Document |
| 00002777211 | EBGLYSS PEN | lebrikizumab-lbkz | PEN INJCTR | 250 mg/2 mL | N | Y | PA Document |
| 00002779701 | EBGLYSS SYRINGE | lebrikizumab-lbkz | SYRINGE | 250 mg/2 mL | N | Y | PA Document |
| 00002779711 | EBGLYSS SYRINGE | lebrikizumab-lbkz | SYRINGE | 250 mg/2 mL | N | Y | PA Document |
| 00173089201 | NUCALA | mepolizumab | AUTO INJCT | 100 mg/mL | N | Y | PA Document |
| 00173089261 | NUCALA | mepolizumab | AUTO INJCT | 100 mg/mL | N | Y | PA Document |
| 00173089242 | NUCALA | mepolizumab | SYRINGE | 100 mg/mL | N | Y | PA Document |
| 00173090442 | NUCALA | mepolizumab | SYRINGE | 40 mg/0.4 mL | N | Y | PA Document |
| 00173088101 | NUCALA | mepolizumab | VIAL | 100 mg | N | Y | PA Document |
| 00173088161 | NUCALA | mepolizumab | VIAL | 100 mg | N | Y | PA Document |
| 00299622010 | NEMLUVIO | nemolizumab-ilto | PEN INJCTR | 30 mg | N | Y | PA Document |
| 00299622015 | NEMLUVIO | nemolizumab-ilto | PEN INJCTR | 30 mg | N | Y | PA Document |
| 50242021555 | XOLAIR | omalizumab | AUTO INJCT | 150 mg/mL | N | Y | PA Document |
| 50242022755 | XOLAIR | omalizumab | AUTO INJCT | 300 mg/2 mL | N | Y | PA Document |
| 50242022799 | XOLAIR | omalizumab | AUTO INJCT | 300 mg/2 mL | N | Y | PA Document |
| 50242021455 | XOLAIR | omalizumab | AUTO INJCT | 75 mg/0.5 mL | N | Y | PA Document |
| 50242021501 | XOLAIR | omalizumab | SYRINGE | 150 mg/mL | N | Y | PA Document |
| 50242021503 | XOLAIR | omalizumab | SYRINGE | 150 mg/mL | N | Y | PA Document |
| 50242021586 | XOLAIR | omalizumab | SYRINGE | 150 mg/mL | N | Y | PA Document |
| 50242022701 | XOLAIR | omalizumab | SYRINGE | 300 mg/2 mL | N | Y | PA Document |
| 50242022786 | XOLAIR | omalizumab | SYRINGE | 300 mg/2 mL | N | Y | PA Document |
| 50242021401 | XOLAIR | omalizumab | SYRINGE | 75 mg/0.5 mL | N | Y | PA Document |
| 50242021403 | XOLAIR | omalizumab | SYRINGE | 75 mg/0.5 mL | N | Y | PA Document |
| 50242004062 | XOLAIR | omalizumab | VIAL | 150 mg | N | Y | PA Document |
| 50242004086 | XOLAIR | omalizumab | VIAL | 150 mg | N | Y | PA Document |
| 59310061031 | CINQAIR | reslizumab | VIAL | 10 mg/mL | N | Y | PA Document |
| 59310061033 | CINQAIR | reslizumab | VIAL | 10 mg/mL | N | Y | PA Document |
| 55513012301 | TEZSPIRE | tezepelumab-ekko | PEN INJCTR | 210 mg/1.91 mL (110 mg/mL) | N | Y | PA Document |
| 55513011201 | TEZSPIRE | tezepelumab-ekko | SYRINGE | 210 mg/1.91 mL (110 mg/mL) | N | Y | PA Document |
| 55513011296 | TEZSPIRE | tezepelumab-ekko | SYRINGE | 210 mg/1.91 mL (110 mg/mL) | N | Y | PA Document |
| 50222035000 | ADBRY AUTOINJECTOR | tralokinumab-ldrm | AUTO INJCT | 300 mg/2 mL | N | Y | PA Document |
| 50222035001 | ADBRY AUTOINJECTOR | tralokinumab-ldrm | AUTO INJCT | 300 mg/2 mL | N | Y | PA Document |
| 50222035002 | ADBRY AUTOINJECTOR | tralokinumab-ldrm | AUTO INJCT | 300 mg/2 mL | N | Y | PA Document |
| 50222034602 | ADBRY | tralokinumab-ldrm | SYRINGE | 150 mg/mL | N | Y | PA Document |
| 50222034604 | ADBRY | tralokinumab-ldrm | SYRINGE | 150 mg/mL | N | Y | PA Document |
| 50222034622 | ADBRY | tralokinumab-ldrm | SYRINGE | 150 mg/mL | N | Y | PA Document |
| 50222034692 | ADBRY | tralokinumab-ldrm | SYRINGE | 150 mg/mL | N | Y | PA Document |