Amyotrophic Lateral Sclerosis

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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
39822450001 EDARAVONE edaravone INFUS. BTL 30 mg/100 mL N Y N Pharmacy PA
39822450002 EDARAVONE edaravone INFUS. BTL 30 mg/100 mL N Y N Pharmacy PA
39822451001 EDARAVONE edaravone INFUS. BTL 60 mg/100 mL N Y N Pharmacy PA
70510232101 RADICAVA ORS edaravone ORAL SUSP 105 mg/5 mL N Y N Pharmacy PA
70510232102 RADICAVA ORS edaravone ORAL SUSP 105 mg/5 mL N Y N Pharmacy PA
70510232201 RADICAVA ORS edaravone ORAL SUSP 105 mg/5 mL N Y N Pharmacy PA
00781352720 EDARAVONE edaravone PIGGYBACK 30 mg/100 mL N Y N Pharmacy PA
00781352794 EDARAVONE edaravone PIGGYBACK 30 mg/100 mL N Y N Pharmacy PA
66794025961 EDARAVONE edaravone PIGGYBACK 30 mg/100 mL N Y N Pharmacy PA
66794025964 EDARAVONE edaravone PIGGYBACK 30 mg/100 mL N Y N Pharmacy PA
81298705001 EDARAVONE edaravone PIGGYBACK 30 mg/100 mL N Y N Pharmacy PA
81298705003 EDARAVONE edaravone PIGGYBACK 30 mg/100 mL N Y N Pharmacy PA
70510217101 RADICAVA edaravone PIGGYBACK 30 mg/100 mL N Y N Pharmacy PA
70510217102 RADICAVA edaravone PIGGYBACK 30 mg/100 mL N Y N Pharmacy PA
43598096111 EDARAVONE edaravone PIGGYBACK 60 mg/100 mL N Y N Pharmacy PA
70726030401 TEGLUTIK riluzole ORAL SUSP 50 mg/10 mL N Y N  
70726030501 TEGLUTIK riluzole ORAL SUSP 50 mg/10 mL N Y N  
70726030601 TEGLUTIK riluzole ORAL SUSP 50 mg/10 mL N Y N  
70726030301 TIGLUTIK riluzole ORAL SUSP 50 mg/10 mL N Y N  
70726030302 TIGLUTIK riluzole ORAL SUSP 50 mg/10 mL N Y N  
70515070060 RILUTEK riluzole TABLET 50 mg Y Y N  
62756053886 RILUZOLE riluzole TABLET 50 mg Y Y N  
67877028660 RILUZOLE riluzole TABLET 50 mg Y Y N  
68462038160 RILUZOLE riluzole TABLET 50 mg Y Y N  
69076020060 RILUZOLE riluzole TABLET 50 mg Y Y N  
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