Fluoroquinolones, 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.
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
ciprofloxacin CIPRO SUS MC REC Y    
ciprofloxacin CIPROFLOXACIN SUS MC REC Y    
ciprofloxacin HCl CIPROFLOXACIN HCL TABLET Y    
ciprofloxacin HCl CIPRO TABLET Y    
levofloxacin LEVOFLOXACIN SOLUTION Y    
levofloxacin LEVOFLOXACIN TABLET Y    
moxifloxacin HCl MOXIFLOXACIN HCL TABLET Y    
ciprofloxacin/ciprofloxa HCl CIPRO XR TBMP 24HR N    
delafloxacin meglumine BAXDELA TABLET N    
lomefloxacin HCl MAXAQUIN TABLET N    
ofloxacin OFLOXACIN TABLET N    
levofloxacin LEVOFLOXACIN SOLUTION