Update to the ​Biosimilar Preferred Drug List

Effective April 3, 2023, the Department will add preferred and non-preferred drugs to the Biosimilar Preferred Drug List (PDL). &²Ô²ú²õ±è; &²Ô²ú²õ±è;

The Department will add the following preferred drugs:  &²Ô²ú²õ±è;

  • C9257 – Avastin, bevacizumab &²Ô²ú²õ±è;

  • Q5119 – Ruxience, rituximab-pvvr  &²Ô²ú²õ±è; &²Ô²ú²õ±è;

The Department will add the following non-preferred drugs:  &²Ô²ú²õ±è;

  • J9312 – Rituxan, rituximab  &²Ô²ú²õ±è;

  • Q5123 – Riabni, rituximab-arrx  &²Ô²ú²õ±è;

  • Q5115 – Truxima, rituximab-abbs &²Ô²ú²õ±è; &²Ô²ú²õ±è;

The Biosimilar PDL, which the Department 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.  &²Ô²ú²õ±è; &²Ô²ú²õ±è;

Non-preferred drugs require a PA form, which is available on the . 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.   &²Ô²ú²õ±è; &²Ô²ú²õ±è;

Biosimilar Preferred Drug List Effective April 3, 2023 &²Ô²ú²õ±è;

 &²Ô²ú²õ±è;

Infliximab and Biosimilars  &²Ô²ú²õ±è;

Preferred Drugs  &²Ô²ú²õ±è;

Non Preferred Drugs (PA required)  &²Ô²ú²õ±è;

Q5121 - AVSOLA, infliximab-axxq  &²Ô²ú²õ±è;

Q5103 - INFLECTRA, infliximab-dyyb  &²Ô²ú²õ±è;

Q5104 - RENFLEXIS, infliximab-abda  &²Ô²ú²õ±è;

J1745 - REMICADE, infliximab  &²Ô²ú²õ±è;

Pegfilgrastim and Biosimilars  &²Ô²ú²õ±è;

Preferred Drugs  &²Ô²ú²õ±è;

Non Preferred Drugs (PA required)  &²Ô²ú²õ±è;

Q5108 - FULPHILA, pegfilgrastim-jmdb  &²Ô²ú²õ±è;

J2506 - NEULASTA, pegfilgrastim  &²Ô²ú²õ±è;

Q5120 - ZIEXTENZO, pegfilgrastim-bmez  &²Ô²ú²õ±è;

Q5122 - NYVEPRIA, pegfilgrastim-apgf  &²Ô²ú²õ±è;

Q5111 - UDENYCA, pegflgrastim-cbqv  &²Ô²ú²õ±è;

Bevacizumab and Biosimilars  &²Ô²ú²õ±è;

Preferred Drugs  &²Ô²ú²õ±è;

Non Preferred Drugs (PA required)  &²Ô²ú²õ±è;

Q5107 - MVASI, bevacizumab-awwb  &²Ô²ú²õ±è;

J9035 - AVASTIN, bevacizumab  &²Ô²ú²õ±è;

Q5118 - ZIRABEV, bevacizumab-bvzr  &²Ô²ú²õ±è;

  &²Ô²ú²õ±è;

C9257 – AVASTIN, bevacizumab  &²Ô²ú²õ±è;

  &²Ô²ú²õ±è;

Trastuzumab and Biosimilars  &²Ô²ú²õ±è;

Preferred Drugs  &²Ô²ú²õ±è;

Non Preferred Drugs (PA required)  &²Ô²ú²õ±è;

Q5116 - TRAZIMERA, trastuzumab-qyyp  &²Ô²ú²õ±è;

J9355 - HERCEPTIN, trastuzumab  &²Ô²ú²õ±è;

  &²Ô²ú²õ±è;

Q5113 - HERZUMA, trastuzumab-pkrb  &²Ô²ú²õ±è;

Q5117 - KANJINTI, trastuzumab-anns  &²Ô²ú²õ±è;

Q5114 - OGIVRI, trastuzumab-dkst  &²Ô²ú²õ±è;

Q5112 - ONTRUZANT, trastuzumab-dttb  &²Ô²ú²õ±è;

Rituximab and Biosimilars  &²Ô²ú²õ±è;

Preferred Drugs  &²Ô²ú²õ±è;

Non Preferred Drug (PA required)  &²Ô²ú²õ±è;

Q5119- Ruxience, rituximab-pvvr  &²Ô²ú²õ±è;

J9312- Rituxan, rituximab  &²Ô²ú²õ±è;

  &²Ô²ú²õ±è;

Q5123- Riabni, rituximab-arrx  &²Ô²ú²õ±è;

  &²Ô²ú²õ±è;

Q5115- Truxima, rituximab-abbs  &²Ô²ú²õ±è;

 &²Ô²ú²õ±è; &²Ô²ú²õ±è;

Please contact your Provider Relations Specialist with questions regarding PA form use.   &²Ô²ú²õ±è;