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:ÌýÌý
- Q5108 – Fulphila, pegfilgrastim-jmdbÌý
Non-preferred drugs:ÌýÌý
- Q5120 – Ziextenzo, pegfilgrastim-bmezÌý
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.ÌýÌý
Non-preferred drugs require a PA. PA forms are 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.Ìý
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Bevacizumab and BiosimilarsÌýÌý |
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Preferred DrugsÌý |
Non Preferred Drugs (PA required)Ìý |
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Ìý C9257 - AVASTIN, bevacizumabÌý |
ÌýJ9035 -Ìý AVASTIN, bevacizumabÌýÌý |
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ÌýQ5118 - ZIRABEV, bevacizumab-bvzrÌýÌý |
ÌýQ5107 - MVASI, bevacizumab-awwbÌýÌý |
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Infliximab and BiosimilarsÌý |
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Preferred DrugsÌý |
Non Preferred Drugs (PA required)Ìý |
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ÌýQ5121 - AVSOLA, infliximab-axxqÌýÌý |
ÌýJ1745 - REMICADE, infliximabÌýÌý |
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ÌýQ5104 - RENFLEXIS, infliximab-abdaÌýÌý |
ÌýQ5103 - INFLECTRA, infliximab-dyybÌýÌý |
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ÌýPegfilgrastim and BiosimilarsÌýÌý |
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Preferred DrugsÌý |
Non Preferred Drugs (PA required)Ìý |
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ÌýQ5122 - NYVEPRIA, pegfilgrastim-apgfÌýÌý |
ÌýJ2506 - NEULASTA, pegfilgrastimÌýÌý |
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ÌýQ5108 - FULPHILA, pegfilgrastim-jmdbÌýÌý |
ÌýQ5111 - UDENYCA, pegflgrastim-cbqvÌýÌý |
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 Ìý |
ÌýQ5120 - ZIEXTENZO, pegfilgrastim-bmezÌýÌý |
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Rituximab and BiosimilarsÌý |
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Preferred DrugsÌý |
Non Preferred Drugs (PA required)Ìý |
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ÌýQ5119 - RUXIENCE, rituximab-pvvrÌýÌý |
ÌýJ9312 - Rituxan, rituximabÌýÌý |
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 Ìý |
ÌýQ5123 - Riabni, rituximab-arrxÌýÌý |
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 Ìý |
ÌýQ5115 - Truxima, rituximab-abbsÌýÌý |
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ÌýTrastuzumab and BiosimilarsÌýÌý |
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Preferred DrugsÌý |
Non Preferred Drugs (PA required)Ìý |
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ÌýQ5116 - TRAZIMERA, trastuzumab-qyypÌýÌý |
ÌýJ9355 - HERCEPTIN, trastuzumabÌýÌý |
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 Ìý |
ÌýQ5113 - HERZUMA, trastuzumab-pkrbÌýÌý |
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 Ìý |
ÌýQ5117 - KANJINTI, trastuzumab-annsÌýÌý |
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 Ìý |
ÌýQ5114 - OGIVRI, trastuzumab-dkstÌýÌý |
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 Ìý |
ÌýQ5112 - ONTRUZANT, trastuzumab-dttbÌýÌý |
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Please contact your Provider Relations Specialist, Shannon Beggs, with questions for assistance with the PA form.ÌýÌýÌý
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