Macrolides, Oral

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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 but eligible patients will encounter a co-pay at the pharmacy.
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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
azithromycin ZITHROMAX SUSP RECON Y    
azithromycin AZITHROMYCIN SUSP RECON Y    
azithromycin ZITHROMAX TRI-PAK TABLET Y    
azithromycin ZITHROMAX TABLET Y    
azithromycin AZITHROMYCIN TABLET Y    
clarithromycin CLARITHROMYCIN TABLET Y    
azithromycin AZITHROMYCIN PACKET N    
azithromycin ZITHROMAX PACKET N    
clarithromycin CLARITHROMYCIN SUSP RECON N    
clarithromycin CLARITHROMYCIN ER TAB ER 24H N    
erythromycin base ERYTHROMYCIN BASE CAPSULE DR N    
erythromycin base ERYTHROMYCIN CAPSULE DR N    
erythromycin base PCE TAB PART N    
erythromycin base ERYTHROMYCIN TABLET N    
erythromycin base ERY-TAB TABLET DR N    
erythromycin ethylsuccinate ERYTHROMYCIN ETHYLSUCCINATE SUSP RECON N    
erythromycin ethylsuccinate ERYPED 200 SUSP RECON N    
erythromycin ethylsuccinate E.E.S. 200 SUSP RECON N    
erythromycin ethylsuccinate ERYPED 400 SUSP RECON N    
erythromycin ethylsuccinate E.E.S. 400 TABLET N    
erythromycin ethylsuccinate ERYTHROMYCIN ETHYLSUCCINATE TABLET N    
erythromycin stearate ERYTHROCIN STEARATE TABLET N