Alzheimer's Disease, Targeted Drugs
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 |
|---|---|---|---|---|---|---|---|
| 64406010101 | ADUHELM | aducanumab-avwa | VIAL | 170 mg/1.7 mL (100 mg/mL) | N | Y | PA Document |
| 64406010202 | ADUHELM | aducanumab-avwa | VIAL | 300 mg/3 mL (100 mg/mL) | N | Y | PA Document |
| 00002940101 | KISUNLA | donanemab-azbt | VIAL | 350 mg/20 mL (17.5 mg/mL) | N | Y | PA Document |
| 62856022001 | LEQEMBI IQLIK | lecanemab-irmb | AUTO INJCT | 360 mg/1.8 mL | Y | PA Document | |
| 62856021201 | LEQEMBI | lecanemab-irmb | VIAL | 200 mg/2 mL (100 mg/mL) | N | Y | PA Document |
| 62856021501 | LEQEMBI | lecanemab-irmb | VIAL | 500 mg/5 mL (100 mg/mL) | N | Y | PA Document |