Xanthine Derivatives

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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
aminophylline AMINOPHYLLINE SYRINGE    
aminophylline AMINOPHYLLINE VIAL    
caffeine NO DOZ TABLET    
caffeine ALERTNESS AID TABLET    
caffeine STAY AWAKE TABLET    
caffeine VIVARIN TABLET    
caffeine citrate CAFFEINE CITRATE SOLUTION    
caffeine citrate CAFCIT VIAL    
caffeine citrate CAFFEINE CITRATE VIAL    
caffeine/sodium benzoate CAFFEINE AND SODIUM BENZOATE VIAL    
dyphylline LUFYLLIN-400 TABLET    
dyphylline DILOR TABLET    
oxtriphylline CHOLEDYL SA TABLET ER    
theophylline anhydrous THEO-24 CAP ER 24H    
theophylline anhydrous THEOPHYLLINE ELIXIR    
theophylline anhydrous ELIXOPHYLLIN ELIXIR    
theophylline anhydrous THEOPHYLLINE SOLUTION    
theophylline anhydrous THEOPHYLLINE ANHYDROUS TAB ER 12H    
theophylline anhydrous QUIBRON-T/SR TAB ER 12H    
theophylline anhydrous THEOPHYLLINE TAB ER 24H    
theophylline in dextrose 5 % THEOPHYLLINE IN 5% DEXTROSE IV SOLN