Iron Replacemant & Hematinics, Not Oral
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 |
|---|---|---|---|---|---|---|---|
| 73554311101 | ZYNTEGLO | betibeglogene autotemcel | PLAST. BAG | 2 x 10exp6 to 20 x 10exp6 cell/mL | N | Y | PA Document |
| 00517060201 | INJECTAFER | ferric carboxymaltose | VIAL | 100 mg iron/2 mL | Y | ||
| 00517065001 | INJECTAFER | ferric carboxymaltose | VIAL | 750 mg iron/15 mL | Y | ||
| 73594931001 | MONOFERRIC | ferric derisomaltose | VIAL | 1,000 mg iron/10 mL | Y | ||
| 59338077501 | FERAHEME | ferumoxytol | VIAL | 510 mg/17 mL (30 mg/mL) | Y | ||
| 00781315401 | FERUMOXYTOL | ferumoxytol | VIAL | 510 mg/17 mL (30 mg/mL) | Y | ||
| 67457063800 | IRON SUCROSE | iron sucrose complex | VIAL | 100 mg iron/5 mL | Y | ||
| 67457063810 | IRON SUCROSE | iron sucrose complex | VIAL | 100 mg iron/5 mL | Y | ||
| 67457063825 | IRON SUCROSE | iron sucrose complex | VIAL | 100 mg iron/5 mL | Y | ||
| 76329920101 | IRON SUCROSE | iron sucrose complex | VIAL | 100 mg iron/5 mL | Y | ||
| 00517234001 | VENOFER | iron sucrose complex | VIAL | 100 mg iron/5 mL | Y | ||
| 00517234010 | VENOFER | iron sucrose complex | VIAL | 100 mg iron/5 mL | Y | ||
| 00517234025 | VENOFER | iron sucrose complex | VIAL | 100 mg iron/5 mL | Y | ||
| 00517234099 | VENOFER | iron sucrose complex | VIAL | 100 mg iron/5 mL | Y | ||
| 49230053401 | VENOFER | iron sucrose complex | VIAL | 100 mg iron/5 mL | Y | ||
| 49230053410 | VENOFER | iron sucrose complex | VIAL | 100 mg iron/5 mL | Y | ||
| 49230053425 | VENOFER | iron sucrose complex | VIAL | 100 mg iron/5 mL | Y | ||
| 67457063900 | IRON SUCROSE | iron sucrose complex | VIAL | 200 mg iron/10 mL | Y | ||
| 67457063910 | IRON SUCROSE | iron sucrose complex | VIAL | 200 mg iron/10 mL | Y | ||
| 76329920205 | IRON SUCROSE | iron sucrose complex | VIAL | 200 mg iron/10 mL | Y | ||
| 00517231001 | VENOFER | iron sucrose complex | VIAL | 200 mg iron/10 mL | Y | ||
| 00517231005 | VENOFER | iron sucrose complex | VIAL | 200 mg iron/10 mL | Y | ||
| 67457095700 | IRON SUCROSE | iron sucrose complex | VIAL | 50 mg iron/2.5 mL | Y | ||
| 67457095799 | IRON SUCROSE | iron sucrose complex | VIAL | 50 mg iron/2.5 mL | Y | ||
| 76329920001 | IRON SUCROSE | iron sucrose complex | VIAL | 50 mg iron/2.5 mL | Y | ||
| 00517232501 | VENOFER | iron sucrose complex | VIAL | 50 mg iron/2.5 mL | Y | ||
| 00517232510 | VENOFER | iron sucrose complex | VIAL | 50 mg iron/2.5 mL | Y | ||
| 49230053001 | VENOFER | iron sucrose complex | VIAL | 50 mg iron/2.5 mL | Y | ||
| 49230053010 | VENOFER | iron sucrose complex | VIAL | 50 mg iron/2.5 mL | Y | ||
| 49230053025 | VENOFER | iron sucrose complex | VIAL | 50 mg iron/2.5 mL | Y | ||
| 82737007301 | APHEXDA | motixafortide acetate | VIAL | 62 mg | Y | ||
| 00024586201 | MOZOBIL | plerixafor | VIAL | 24 mg/1.2 mL (20 mg/mL) | Y | ||
| 00480432001 | PLERIXAFOR | plerixafor | VIAL | 24 mg/1.2 mL (20 mg/mL) | Y | ||
| 25021041601 | PLERIXAFOR | plerixafor | VIAL | 24 mg/1.2 mL (20 mg/mL) | Y | ||
| 43598030823 | PLERIXAFOR | plerixafor | VIAL | 24 mg/1.2 mL (20 mg/mL) | Y | ||
| 55150035601 | PLERIXAFOR | plerixafor | VIAL | 24 mg/1.2 mL (20 mg/mL) | Y | ||
| 65219028412 | PLERIXAFOR | plerixafor | VIAL | 24 mg/1.2 mL (20 mg/mL) | Y | ||
| 70121169402 | PLERIXAFOR | plerixafor | VIAL | 24 mg/1.2 mL (20 mg/mL) | Y | ||
| 70710120801 | PLERIXAFOR | plerixafor | VIAL | 24 mg/1.2 mL (20 mg/mL) | Y | ||
| 71288015501 | PLERIXAFOR | plerixafor | VIAL | 24 mg/1.2 mL (20 mg/mL) | Y | ||
| 72205024901 | PLERIXAFOR | plerixafor | VIAL | 24 mg/1.2 mL (20 mg/mL) | Y | ||
| 00024279201 | FERRLECIT | sodium ferric gluconat/sucrose | VIAL | 62.5 mg/5 mL | Y | ||
| 00024279210 | FERRLECIT | sodium ferric gluconat/sucrose | VIAL | 62.5 mg/5 mL | Y | ||
| 00024279401 | FERRLECIT | sodium ferric gluconat/sucrose | VIAL | 62.5 mg/5 mL | Y | ||
| 00024279410 | FERRLECIT | sodium ferric gluconat/sucrose | VIAL | 62.5 mg/5 mL | Y | ||
| 00143929801 | SOD FERRIC GLUCONATE COMPLEX | sodium ferric gluconat/sucrose | VIAL | 62.5 mg/5 mL | Y | ||
| 00143929810 | SOD FERRIC GLUCONATE COMPLEX | sodium ferric gluconat/sucrose | VIAL | 62.5 mg/5 mL | Y | ||
| 00143957001 | SOD FERRIC GLUCONATE COMPLEX | sodium ferric gluconat/sucrose | VIAL | 62.5 mg/5 mL | Y | ||
| 00143957010 | SOD FERRIC GLUCONATE COMPLEX | sodium ferric gluconat/sucrose | VIAL | 62.5 mg/5 mL | Y |