Update to the Biosimilar Preferred Drug List (PDL)
Effective January 1, 2025, the Department will add preferred and non-preferred drugs to the Biosimilar PDL, listed below.
Preferred drugs:
- Q5108 – Fulphila, pegfilgrastim-jmdb
Non-preferred drugs:
- Q5120 – Ziextenzo, pegfilgrastim-bmez
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. PA forms are 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.
|
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 |
J2506 - NEULASTA, pegfilgrastim |
|
Q5108 - FULPHILA, pegfilgrastim-jmdb |
Q5111 - UDENYCA, pegflgrastim-cbqv |
|
|
Q5120 - ZIEXTENZO, pegfilgrastim-bmez |
|
Rituximab and Biosimilars |
|
|
Preferred Drugs |
Non Preferred Drugs (PA required) |
|
Q5119 - RUXIENCE, rituximab-pvvr |
J9312 - Rituxan, rituximab |
|
|
Q5123 - Riabni, rituximab-arrx |
|
|
Q5115 - Truxima, rituximab-abbs |
|
Trastuzumab and Biosimilars |
|
|
Preferred Drugs |
Non Preferred Drugs (PA required) |
|
Q5116 - TRAZIMERA, trastuzumab-qyyp |
J9355 - 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 for assistance with the PA form.
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