Misc Antivirals

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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
55150015410 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
55150015520 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
63323032503 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
63323032509 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
63323032510 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
63323032514 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
63323032520 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
63323032524 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
63323032541 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
63323032543 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
65219062202 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
65219062210 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
65219062404 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
65219062420 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
70436003082 ACYCLOVIR SODIUM acyclovir sodium VIAL 50 mg/mL Y N  
61755001800 INMAZEB (NATIONAL STOCKPILE) atoltivimab-maftiv-odesiv-ebgn VIAL 241.7mg-241.7mg-241.7mg/14.5mL (16.67mg-16.67mg-16.67mg/mL) Y N  
61755001801 INMAZEB (NATIONAL STOCKPILE) atoltivimab-maftiv-odesiv-ebgn VIAL 241.7mg-241.7mg-241.7mg/14.5mL (16.67mg-16.67mg-16.67mg/mL) Y N  
23155021631 CIDOFOVIR cidofovir VIAL 75 mg/mL Y N  
67457021005 CIDOFOVIR cidofovir VIAL 75 mg/mL Y N  
00310106101 CILGAVIMAB (EUA) cilgavimab VIAL 150 mg/1.5 mL Y N  
00006507301 ENFLONSIA clesrovimab-cfor SYRINGE 105 mg/0.7 mL Y N  
00006507302 ENFLONSIA clesrovimab-cfor SYRINGE 105 mg/0.7 mL Y N  
00006507399 ENFLONSIA clesrovimab-cfor SYRINGE 105 mg/0.7 mL Y N  
00143919201 FOSCARNET SODIUM foscarnet sodium INFUS. BTL 24 mg/mL Y N  
23155077131 FOSCARNET SODIUM foscarnet sodium INFUS. BTL 24 mg/mL Y N  
63323087550 FOSCARNET SODIUM foscarnet sodium INFUS. BTL 24 mg/mL Y N  
25021018984 FOSCARNET SODIUM foscarnet sodium PLAST. BAG 24 mg/mL Y N  
43066008910 FOSCARNET SODIUM foscarnet sodium PLAST. BAG 24 mg/mL Y N  
70121174401 FOSCARNET SODIUM foscarnet sodium PLAST. BAG 24 mg/mL Y N  
70121174402 FOSCARNET SODIUM foscarnet sodium PLAST. BAG 24 mg/mL Y N  
00143929901 GANCICLOVIR SODIUM ganciclovir sodium VIAL 500 mg Y N  
00143929910 GANCICLOVIR SODIUM ganciclovir sodium VIAL 500 mg Y N  
42023017301 GANCICLOVIR SODIUM ganciclovir sodium VIAL 500 mg Y N  
42023017325 GANCICLOVIR SODIUM ganciclovir sodium VIAL 500 mg Y N  
63323031501 GANCICLOVIR SODIUM ganciclovir sodium VIAL 500 mg Y N  
63323031510 GANCICLOVIR SODIUM ganciclovir sodium VIAL 500 mg Y N  
63323031594 GANCICLOVIR SODIUM ganciclovir sodium VIAL 500 mg Y N  
70436008955 GANCICLOVIR SODIUM ganciclovir sodium VIAL 500 mg Y N  
70436023155 GANCICLOVIR SODIUM ganciclovir sodium VIAL 500 mg Y N  
25021018510 GANCICLOVIR SODIUM ganciclovir sodium VIAL 500 mg/10 mL (50 mg/mL) Y N  
61958340101 YEZTUGO lenacapavir sodium TABLET 300 mg Y Y N  
61958340201 YEZTUGO lenacapavir sodium VIAL 463.5 mg/1.5 mL (309 mg/mL) Y Y N  
61958340301 YEZTUGO lenacapavir sodium VIAL 463.5 mg/1.5 mL (309 mg/mL) Y Y N  
00006508501 PREVYMIS letermovir PELET PACK 120 mg Y N  
00006508599 PREVYMIS letermovir PELET PACK 120 mg Y N  
00006508601 PREVYMIS letermovir PELET PACK 20 mg Y N  
00006508699 PREVYMIS letermovir PELET PACK 20 mg Y N  
00006307501 PREVYMIS letermovir TABLET 240 mg Y N  
00006307502 PREVYMIS letermovir TABLET 240 mg Y N  
00006307503 PREVYMIS letermovir TABLET 240 mg Y N  
00006307504 PREVYMIS letermovir TABLET 240 mg Y N  
00006307601 PREVYMIS letermovir TABLET 480 mg Y N  
00006307602 PREVYMIS letermovir TABLET 480 mg Y N  
00006307603 PREVYMIS letermovir TABLET 480 mg Y N  
00006307604 PREVYMIS letermovir TABLET 480 mg Y N  
00006500301 PREVYMIS letermovir VIAL 240 mg/12 mL Y N  
00006500302 PREVYMIS letermovir VIAL 240 mg/12 mL Y N  
00006500401 PREVYMIS letermovir VIAL 480 mg/24 mL Y N  
00006500402 PREVYMIS letermovir VIAL 480 mg/24 mL Y N  
64764080028 LIVTENCITY maribavir TABLET 200 mg Y N  
64764080056 LIVTENCITY maribavir TABLET 200 mg Y N  
66658023101 SYNAGIS palivizumab VIAL 100 mg/mL Y N Pharmacy PA
66658023001 SYNAGIS palivizumab VIAL 50 mg/0.5 mL Y N Pharmacy PA
42494042301 RIBAVIRIN ribavirin VIAL-NEB 6 gram Y N  
68382039501 RIBAVIRIN ribavirin VIAL-NEB 6 gram Y N  
68382039504 RIBAVIRIN ribavirin VIAL-NEB 6 gram Y N  
62559038530 VEREGEN sinecatechins OINT. (G) 15 % Y N  
00310889501 TIXAGEVIMAB (EUA) tixagevimab VIAL 150 mg/1.5 mL Y N  
00310744202 EVUSHELD (EUA) tixagevimab/cilgavimab VIAL 150 mg/1.5 mL (x1)-150 mg/1.5 mL (x1) Y N  
61269048510 VALCYTE valganciclovir HCl SOLN RECON 50 mg/mL Y N  
00591257920 VALGANCICLOVIR HCL valganciclovir HCl SOLN RECON 50 mg/mL Y N  
00904741904 VALGANCICLOVIR HCL valganciclovir HCl SOLN RECON 50 mg/mL Y N  
27241015919 VALGANCICLOVIR HCL valganciclovir HCl SOLN RECON 50 mg/mL Y N  
31722083710 VALGANCICLOVIR HCL valganciclovir HCl SOLN RECON 50 mg/mL Y N  
59651044401 VALGANCICLOVIR HCL valganciclovir HCl SOLN RECON 50 mg/mL Y N  
60687076513 VALGANCICLOVIR HCL valganciclovir HCl SOLN RECON 50 mg/mL Y N  
70010005140 VALGANCICLOVIR HCL valganciclovir HCl SOLN RECON 50 mg/mL Y N  
70069081001 VALGANCICLOVIR HCL valganciclovir HCl SOLN RECON 50 mg/mL Y N  
71921021012 VALGANCICLOVIR HCL valganciclovir HCl SOLN RECON 50 mg/mL Y N  
72205001901 VALGANCICLOVIR HCL valganciclovir HCl SOLN RECON 50 mg/mL Y N  
72603017401 VALGANCICLOVIR HCL valganciclovir HCl SOLN RECON 50 mg/mL Y N  
61269048060 VALCYTE valganciclovir HCl TABLET 450 mg Y N  
00904679604 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
00904679610 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
27241015860 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
31722083260 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
50268078711 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
50268078712 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
55111076260 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
64380015301 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
64380016101 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
65862075360 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
68084096518 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
68084096519 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
68084096525 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
68084096595 VALGANCICLOVIR HCL valganciclovir HCl TABLET 450 mg Y N  
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