Update to the ​Biosimilar Preferred Drug List (PDL)​

Dec 01, 2023

Effective January 4, 2024, the Department will add preferred and non-preferred drugs to the PDL. 

The Department will add the following preferred drugs:  

• Q5122 – Nyvepria, pegfilgrastim-apgf  

The Department will add the following non-preferred drugs:  

• Q5108 – Fulphila, pegfilgrastim-jmdb 

• Q5107 – Mvasi, bevacizumab-awwb  

The Biosimilar PDL, implemented in 2022, establishes preferred and non-preferred Physician-Administered Drugs (PADs). Preferred drugs are available without a Prior Authorization (PA). Providers must try preferred drugs first.   

Non-preferred drugs require a PA form which is available on the Health PAS Online Portal. For the Department to consider approving a non-preferred drug, the provider must include with their PA request documentation of preferred drug failure due to lack of efficacy, intolerable side effects to the preferred drug, or clinical exceptions. Clinical exceptions include the presence of a condition that prevents usage of the preferred drug or a significant drug interaction between another drug and the preferred drug.   

 

Biosimilar Preferred Drug List Effective January 4, 2024  

Bevacizumab and Biosimilars
Preferred Drugs	Non Preferred Drugs (PA required)
C9257 - AVASTIN, bevacizumab	J9035 -  AVASTIN, bevacizumab
Q5118 - ZIRABEV, bevacizumab-bvzr	Q5107 - MVASI, bevacizumab-awwb
Infliximab and Biosimilars
Preferred Drugs	Non Preferred Drugs (PA required)
Q5121 - AVSOLA, infliximab-axxq	J1745 - REMICADE, infliximab
Q5104 - RENFLEXIS, infliximab-abda	Q5103 - INFLECTRA, infliximab-dyyb
Pegfilgrastim and Biosimilars
Preferred Drugs	Non Preferred Drugs (PA required)
Q5122 - NYVEPRIA, pegfilgrastim-apgf	J2505 - NEULASTA, pegfilgrastim
Q5120 - ZIEXTENZO, pegfilgrastim-bmez	Q5108 - FULPHILA, pegfilgrastim-jmdb
	Q5111 - UDENYCA, pegflgrastim-cbqv
Trastuzumab and Biosimilars
Preferred Drugs	Non Preferred Drugs (PA required)
Q5116 - TRAZIMERA, trastuzumab-qyyp	J9344 - HERCEPTIN, trastuzumab
	Q5113 - HERZUMA, trastuzumab-pkrb
	Q5117 - KANJINTI, trastuzumab-anns
	Q5114 - OGIVRI, trastuzumab-dkst
	Q5112 - ONTRUZANT, trastuzumab-dttb

 

Please contact your Provider Relations Specialist, Shannon Beggs, with questions regarding PA form use.