Sickle Cell Gene Therapy
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 | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 51167029001 | CASGEVY | exagamglogene autotemcel | VIAL | 4 x 10exp6 to 13 x 10exp6 cell/mL | Y | Y | N | Pharmacy PA |
| 51167029009 | CASGEVY | exagamglogene autotemcel | VIAL | 4 x 10exp6 to 13 x 10exp6 cell/mL | Y | Y | N | Pharmacy PA |
| 73554111101 | LYFGENIA | lovotibeglogene autotemcel | PLAST. BAG | 1.7 x 10exp6 to 20 x 10exp6 cell/mL | Y | Y | N | Pharmacy PA |