Streptomycins

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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
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 HCL-D5W FROZ.PIGGY    
vancomycin HCl in 5 % dextrose VANCOMYCIN FROZ.PIGGY    
vancomycin HCl in 5 % dextrose VANCOMYCIN HCL FROZ.PIGGY    
vancomycin/0.9 % sod chloride VANCOMYCIN HCL-0.9% NACL FROZ.PIGGY    
vancomycin/water for inj (PEG) VANCOMYCIN HCL PIGGYBACK