Penicillin

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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
amoxicillin AMOXICILLIN CAPSULE    
amoxicillin AMOXICILLIN SUSP RECON    
amoxicillin AMOXICILLIN TAB CHEW    
amoxicillin AMOXICILLIN TABLET    
ampicillin sodium TOTACILLIN-N PIGGYBACK    
ampicillin sodium TOTACILLIN-N VIAL    
ampicillin sodium AMPICILLIN SODIUM VIAL    
ampicillin sodium AMPICILLIN SODIUM VIAL PORT    
ampicillin sodium/sulbactam Na AMPICILLIN-SULBACTAM VIAL    
ampicillin sodium/sulbactam Na UNASYN VIAL    
ampicillin sodium/sulbactam Na AMPICILLIN-SULBACTAM VIAL PORT    
ampicillin trihydrate AMPICILLIN TRIHYDRATE CAPSULE    
dicloxacillin sodium DICLOXACILLIN SODIUM CAPSULE    
dicloxacillin sodium DYNAPEN SUSP RECON    
nafcillin in dextrose,iso-osm NALLPEN-ISO-OSMOTIC DEXTROSE FROZ.PIGGY    
nafcillin in dextrose,iso-osm NAFCILLIN FROZ.PIGGY    
nafcillin sodium NALLPEN PIGGYBACK    
nafcillin sodium NALLPEN VIAL    
nafcillin sodium NAFCILLIN SODIUM VIAL    
nafcillin sodium NAFCILLIN SODIUM VIAL PORT    
nafcillin sodium/D5W NALLPEN IN DEXTROSE PIGGYBACK    
nafcillin sodium/D5W NAFCILL IN DEXTROSE PIGGYBACK    
oxacillin in dextrose(iso-osm) OXACILLIN FROZ.PIGGY    
oxacillin sodium BACTOCILL CAPSULE    
oxacillin sodium OXACILLIN SODIUM SUSP RECON    
oxacillin sodium OXACILLIN SODIUM VIAL    
oxacillin sodium OXACILLIN SODIUM VIAL PORT    
pen G benz/pen G procaine BICILLIN C-R SYRINGE    
pen G pot/dextrose-water PENICILLIN GK-ISO-OSM DEXTROSE FROZ.PIGGY    
penicillin G benzathine BICILLIN L-A SYRINGE    
penicillin G potassium PFIZERPEN VIAL    
penicillin G potassium PENICILLIN G POTASSIUM VIAL    
penicillin G potassium/D5W PENICILLIN G POTASSIUM IN D5W PIGGYBACK    
penicillin G procaine PENICILLIN G PROCAINE SYRINGE    
penicillin G sodium PENICILLIN G SODIUM VIAL    
penicillin V potassium PENICILLIN V POTASSIUM SOLN RECON    
penicillin V potassium PENICILLIN V POTASSIUM TABLET    
piperacillin sodium PIPRACIL VIAL    
piperacillin sodium/D5W PIPRACIL IN DEXTROSE PIGGYBACK    
piperacillin sodium/tazobactam PIPERACILLIN-TAZOBACTAM VIAL    
piperacillin sodium/tazobactam ZOSYN VIAL    
piperacillin sodium/tazobactam PIPERACILLIN-TAZOBACTAM VIAL PORT    
piperacillin-tazo-dextrose,iso ZOSYN FROZ.PIGGY    
ticarcillin disodium TICAR PIGGYBACK    
ticarcillin disodium TICAR VIAL    
ticarcillin disodium/D5W TICAR IN DEXTROSE PIGGYBACK