Targeted Immune Modulators for Asthma and Atopic Dermatitis

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00069033530 CIBINQO abrocitinib TABLET 100 mg N Y N Pharmacy PA
00069043530 CIBINQO abrocitinib TABLET 200 mg N Y N Pharmacy PA
00069023530 CIBINQO abrocitinib TABLET 50 mg N Y N Pharmacy PA
00310183030 FASENRA PEN benralizumab AUTO INJCT 30 mg/mL N Y N Pharmacy PA
00310183085 FASENRA PEN benralizumab AUTO INJCT 30 mg/mL N Y N Pharmacy PA
00310174501 FASENRA benralizumab SYRINGE 10 mg/0.5 mL N Y N Pharmacy PA
00310173030 FASENRA benralizumab SYRINGE 30 mg/mL N Y N Pharmacy PA
00310173085 FASENRA benralizumab SYRINGE 30 mg/mL N Y N Pharmacy PA
00024591900 DUPIXENT PEN dupilumab PEN INJCTR 200 mg/1.14 mL N Y N Pharmacy PA
00024591901 DUPIXENT PEN dupilumab PEN INJCTR 200 mg/1.14 mL N Y N Pharmacy PA
00024591902 DUPIXENT PEN dupilumab PEN INJCTR 200 mg/1.14 mL N Y N Pharmacy PA
00024591920 DUPIXENT PEN dupilumab PEN INJCTR 200 mg/1.14 mL N Y N Pharmacy PA
00024591500 DUPIXENT PEN dupilumab PEN INJCTR 300 mg/2 mL N Y N Pharmacy PA
00024591501 DUPIXENT PEN dupilumab PEN INJCTR 300 mg/2 mL N Y N Pharmacy PA
00024591502 DUPIXENT PEN dupilumab PEN INJCTR 300 mg/2 mL N Y N Pharmacy PA
00024591520 DUPIXENT PEN dupilumab PEN INJCTR 300 mg/2 mL N Y N Pharmacy PA
00024591100 DUPIXENT SYRINGE dupilumab SYRINGE 100 mg/0.67 mL N Y N Pharmacy PA
00024591102 DUPIXENT SYRINGE dupilumab SYRINGE 100 mg/0.67 mL N Y N Pharmacy PA
00024591800 DUPIXENT SYRINGE dupilumab SYRINGE 200 mg/1.14 mL N Y N Pharmacy PA
00024591801 DUPIXENT SYRINGE dupilumab SYRINGE 200 mg/1.14 mL N Y N Pharmacy PA
00024591802 DUPIXENT SYRINGE dupilumab SYRINGE 200 mg/1.14 mL N Y N Pharmacy PA
00024591400 DUPIXENT SYRINGE dupilumab SYRINGE 300 mg/2 mL N Y N Pharmacy PA
00024591401 DUPIXENT SYRINGE dupilumab SYRINGE 300 mg/2 mL N Y N Pharmacy PA
00024591402 DUPIXENT SYRINGE dupilumab SYRINGE 300 mg/2 mL N Y N Pharmacy PA
00002777201 EBGLYSS PEN lebrikizumab-lbkz PEN INJCTR 250 mg/2 mL N Y N Pharmacy PA
00002777211 EBGLYSS PEN lebrikizumab-lbkz PEN INJCTR 250 mg/2 mL N Y N Pharmacy PA
00002779701 EBGLYSS SYRINGE lebrikizumab-lbkz SYRINGE 250 mg/2 mL N Y N Pharmacy PA
00002779711 EBGLYSS SYRINGE lebrikizumab-lbkz SYRINGE 250 mg/2 mL N Y N Pharmacy PA
00173089201 NUCALA mepolizumab AUTO INJCT 100 mg/mL N Y N Pharmacy PA
00173089261 NUCALA mepolizumab AUTO INJCT 100 mg/mL N Y N Pharmacy PA
00173089242 NUCALA mepolizumab SYRINGE 100 mg/mL N Y N Pharmacy PA
00173090442 NUCALA mepolizumab SYRINGE 40 mg/0.4 mL N Y N Pharmacy PA
00173088101 NUCALA mepolizumab VIAL 100 mg N Y N Pharmacy PA
00173088161 NUCALA mepolizumab VIAL 100 mg N Y N Pharmacy PA
00299622010 NEMLUVIO nemolizumab-ilto PEN INJCTR 30 mg N Y N Pharmacy PA
00299622015 NEMLUVIO nemolizumab-ilto PEN INJCTR 30 mg N Y N Pharmacy PA
50242021555 XOLAIR omalizumab AUTO INJCT 150 mg/mL N Y N Pharmacy PA
50242022755 XOLAIR omalizumab AUTO INJCT 300 mg/2 mL N Y N Pharmacy PA
50242022799 XOLAIR omalizumab AUTO INJCT 300 mg/2 mL N Y N Pharmacy PA
50242021455 XOLAIR omalizumab AUTO INJCT 75 mg/0.5 mL N Y N Pharmacy PA
50242021501 XOLAIR omalizumab SYRINGE 150 mg/mL N Y N Pharmacy PA
50242021503 XOLAIR omalizumab SYRINGE 150 mg/mL N Y N Pharmacy PA
50242021586 XOLAIR omalizumab SYRINGE 150 mg/mL N Y N Pharmacy PA
50242022701 XOLAIR omalizumab SYRINGE 300 mg/2 mL N Y N Pharmacy PA
50242022786 XOLAIR omalizumab SYRINGE 300 mg/2 mL N Y N Pharmacy PA
50242021401 XOLAIR omalizumab SYRINGE 75 mg/0.5 mL N Y N Pharmacy PA
50242021403 XOLAIR omalizumab SYRINGE 75 mg/0.5 mL N Y N Pharmacy PA
50242004062 XOLAIR omalizumab VIAL 150 mg N Y N Pharmacy PA
50242004086 XOLAIR omalizumab VIAL 150 mg N Y N Pharmacy PA
00078148320 RHAPSIDO remibrutinib TABLET 25 mg N Y N Pharmacy PA
59310061031 CINQAIR reslizumab VIAL 10 mg/mL N Y N Pharmacy PA
59310061033 CINQAIR reslizumab VIAL 10 mg/mL N Y N Pharmacy PA
55513012301 TEZSPIRE tezepelumab-ekko PEN INJCTR 210 mg/1.91 mL (110 mg/mL) N Y N Pharmacy PA
55513011201 TEZSPIRE tezepelumab-ekko SYRINGE 210 mg/1.91 mL (110 mg/mL) N Y N Pharmacy PA
55513011296 TEZSPIRE tezepelumab-ekko SYRINGE 210 mg/1.91 mL (110 mg/mL) N Y N Pharmacy PA
50222035000 ADBRY AUTOINJECTOR tralokinumab-ldrm AUTO INJCT 300 mg/2 mL N Y N Pharmacy PA
50222035001 ADBRY AUTOINJECTOR tralokinumab-ldrm AUTO INJCT 300 mg/2 mL N Y N Pharmacy PA
50222035002 ADBRY AUTOINJECTOR tralokinumab-ldrm AUTO INJCT 300 mg/2 mL N Y N Pharmacy PA
50222034602 ADBRY tralokinumab-ldrm SYRINGE 150 mg/mL N Y N Pharmacy PA
50222034604 ADBRY tralokinumab-ldrm SYRINGE 150 mg/mL N Y N Pharmacy PA
50222034622 ADBRY tralokinumab-ldrm SYRINGE 150 mg/mL N Y N Pharmacy PA
50222034692 ADBRY tralokinumab-ldrm SYRINGE 150 mg/mL N Y N Pharmacy PA
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