Streptomycins
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 |
|---|---|---|---|---|---|
| amikacin sulfate | AMIKACIN SULFATE | VIAL | |||
| gentamicin in NaCl, iso-osm | GENTAMICIN SULFATE IN NS | PIGGYBACK | |||
| gentamicin sulfate | GENTAMICIN SULFATE | VIAL | |||
| gentamicin sulfate/PF | GENTAMICIN SULFATE | VIAL | |||
| gentamicin sulfate/PF | GENTAMICIN SULFATE | VIAL PORT | |||
| neomycin sulfate | NEOMYCIN SULFATE | TABLET | |||
| plazomicin sulfate | ZEMDRI | VIAL | |||
| streptomycin sulfate | STREPTOMYCIN SULFATE | VIAL | |||
| tobramycin sulfate | TOBRAMYCIN SULFATE | VIAL | |||
| tobramycin sulfate | NEBCIN | VIAL | |||
| tobramycin sulfate/D5W | NEBCIN IN DEXTROSE | PIGGYBACK | |||
| tobramycin/sodium chloride | TOBRAMYCIN SULFATE IN NS | PIGGYBACK | |||
| vancomycin HCl | VANCOMYCIN HCL | VIAL PORT | |||
| vancomycin HCl in 5 % dextrose | VANCOMYCIN | FROZ.PIGGY | |||
| vancomycin HCl in 5 % dextrose | VANCOMYCIN HCL | FROZ.PIGGY | |||
| vancomycin HCl in 5 % dextrose | VANCOMYCIN HCL-D5W | FROZ.PIGGY | |||
| vancomycin/0.9 % sod chloride | VANCOMYCIN HCL-0.9% NACL | FROZ.PIGGY | |||
| vancomycin/water for inj (PEG) | VANCOMYCIN HCL | PIGGYBACK |