C-Type Natriuretic Peptides
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 |
|---|---|---|---|---|---|---|---|---|
| 73362020101 | YUVIWEL | navepegritide | VIAL | 1.3 mg | Y | |||
| 73362020102 | YUVIWEL | navepegritide | VIAL | 1.3 mg | Y | |||
| 73362020103 | YUVIWEL | navepegritide | VIAL | 1.3 mg | Y | |||
| 73362020501 | YUVIWEL | navepegritide | VIAL | 1.3 mg | Y | |||
| 73362020201 | YUVIWEL | navepegritide | VIAL | 2.8 mg | Y | |||
| 73362020202 | YUVIWEL | navepegritide | VIAL | 2.8 mg | Y | |||
| 73362020203 | YUVIWEL | navepegritide | VIAL | 2.8 mg | Y | |||
| 73362020601 | YUVIWEL | navepegritide | VIAL | 2.8 mg | Y | |||
| 73362020301 | YUVIWEL | navepegritide | VIAL | 5.5 mg | Y | |||
| 73362020302 | YUVIWEL | navepegritide | VIAL | 5.5 mg | Y | |||
| 73362020303 | YUVIWEL | navepegritide | VIAL | 5.5 mg | Y | |||
| 73362020701 | YUVIWEL | navepegritide | VIAL | 5.5 mg | Y | |||
| 68135008236 | VOXZOGO | vosoritide | VIAL | 0.4 mg | Y | Pharmacy PA | ||
| 68135011966 | VOXZOGO | vosoritide | VIAL | 0.56 mg | Y | Pharmacy PA | ||
| 68135018193 | VOXZOGO | vosoritide | VIAL | 1.2 mg | Y | Pharmacy PA |