IV Solutions and Misc

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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
0.9 % sodium chloride SODIUM CHLORIDE AMPUL    
0.9 % sodium chloride SODIUM CHLORIDE IV SOLN    
0.9 % sodium chloride SODIUM CHLORIDE PGGYBK PRT    
0.9 % sodium chloride SODIUM CHLORIDE PGY VL PRT    
0.9 % sodium chloride SODIUM CHLORIDE VIAL    
AA 2.36%/D7.5W/fat/e-lytes no9 PERIKABIVEN EMULSION    
AA 2.75 %/calcium/lytes/D5W CLINIMIX E IV SOLN    
AA 3.31 %/D9.8W/fat/e-lytes 10 KABIVEN EMULSION    
AA 4.25%/calcium/lytes/dex 10% CLINIMIX E IV SOLN    
AA 5 %/calcium/lytes/dext 20 % CLINIMIX E IV SOLN    
AA 5%/D15W/electrolytes CLINIMIX E IV SOLN    
amino ac 4.25% no.1/D5W/lytes CLINIMIX E IV SOLN    
amino ac 8 %/D10W/electrolytes CLINIMIX E IV SOLN    
amino ac 8 %/D14W/electrolytes CLINIMIX E IV SOLN    
amino acid 6 % in 5 % dextrose CLINIMIX IV SOLN    
amino acid 8 % in D10W CLINIMIX IV SOLN    
amino acid 8 % in D14W CLINIMIX IV SOLN    
amino acids 10 % TROPHAMINE IV SOLN    
amino acids 10 % TRAVASOL IV SOLN    
amino acids 4.25 %/dextrose 5% CLINIMIX IV SOLN    
amino acids 4.25%/dextrose 10% CLINIMIX IV SOLN    
amino acids 5 %/dextrose 15 % CLINIMIX IV SOLN    
amino acids 5 %/dextrose 20 % CLINIMIX IV SOLN    
amino acids 7 % AMINOSYN-HBC IV SOLN    
amino acids 7 %/electrolytes AMINOSYN WITH ELECTROLYTES IV SOLN    
amino acids 8.5 % TRAVASOL IV SOLN    
amino acids 8.5 %/electrolytes TRAVASOL WITH ELECTROLYTES IV SOLN    
amino acids 8.5 %/electrolytes TRAVASOL W/ELECTROLYTES IV SOLN    
amino acids 8.5 %/electrolytes AMINOSYN WITH ELECTROLYTES IV SOLN    
calcium chloride CALCIUM CHLORIDE SYRINGE    
calcium chloride CALCIUM CHLORIDE VIAL    
calcium gluc in NaCl, iso-osm CALCIUM GLUCONATE-NACL PLAST. BAG    
calcium gluconate CALCIUM GLUCONATE AMPUL    
calcium gluconate CALCIUM GLUCONATE VIAL    
chromic chloride CHROMIUM VIAL    
chromium CHROMIUM TABLET    
cupric chloride CUPRIC CHLORIDE VIAL    
cupric chloride COPPER CHLORIDE VIAL    
dex 2.5%-half str lact.ringers DEXTROSE IN LACTATED RINGERS IV SOLN    
dextrose 10 % and 0.2 % NaCl DEXTROSE 10%-0.2% NACL DEHP FR BG    
dextrose 10 % and 0.2 % NaCl DEXTROSE 10%-1/4NS IV SOLN    
dextrose 10 % and 0.45 % NaCl DEXTROSE 10%-0.45% NACL IV SOLN    
dextrose 10 % and 0.9 % NaCl DEXTROSE WITH SODIUM CHLORIDE IV SOLN    
dextrose 10 % in water DEXTROSE IN WATER DEHP FR BG    
dextrose 10 % in water DEXTROSE IN WATER IV SOLN    
dextrose 2.5 % and 0.45 % NaCl DEXTROSE 2.5%-0.45% NACL IV SOLN    
dextrose 2.5 % and 0.45 % NaCl DEXTROSE WITH SODIUM CHLORIDE IV SOLN    
dextrose 2.5 % in water DEXTROSE IN WATER IV SOLN    
dextrose 2.5% in half ringers DEXTROSE IN RINGERS INJECTION IV SOLN    
dextrose 20 % in water DEXTROSE IN WATER IV SOLN    
dextrose 25 % in water DEXTROSE IN WATER SYRINGE    
dextrose 30 % in water DEXTROSE IN WATER IV SOLN    
dextrose 40 % in water DEXTROSE IN WATER IV SOLN    
dextrose 5 % and 0.3 % NaCl DEXTROSE 5%-0.3% NACL IV SOLN    
dextrose 5 % and 0.3 % NaCl DEXTROSE 5%-0.33% NACL IV SOLN    
dextrose 5 % and 0.3 % NaCl DEXTROSE WITH SODIUM CHLORIDE IV SOLN    
dextrose 5 % and 0.9 % NaCl DEXTROSE 5%-0.9% NACL IV SOLN    
dextrose 5 % in Ringer's DEXTROSE IN RINGERS INJECTION IV SOLN    
dextrose 5 % in water DEXTROSE IN WATER IV SOLN    
dextrose 5 % in water GLUCOSE IN WATER IV SOLN    
dextrose 5 % in water DEXTROSE IN WATER PGGYBK PRT    
dextrose 5 % in water DEXTROSE IN WATER PGY VL PRT    
dextrose 5 % in water DEXTROSE IN WATER VIAL    
dextrose 5 %-0.2 % sod chlorid DEXTROSE 5%-0.2% NACL IV SOLN    
dextrose 5 %-0.2 % sod chlorid DEXTROSE 5%-0.225% NACL IV SOLN    
dextrose 5 %-0.2 % sod chlorid DEXTROSE WITH SODIUM CHLORIDE IV SOLN    
dextrose 5 %-0.45 % sod chlord DEXTROSE WITH SODIUM CHLORIDE IV SOLN    
dextrose 5 %-0.45 % sod chlord DEXTROSE 5%-0.45% NACL IV SOLN    
dextrose 5%-lactated ringers DEXTROSE IN LACTATED RINGERS IV SOLN    
dextrose 50 % in water DEXTROSE IN WATER IV SOLN    
dextrose 50 % in water DEXTROSE IN WATER SYRINGE    
dextrose 50 % in water DEXTROSE IN WATER VIAL    
dextrose 60 % in water DEXTROSE IN WATER IV SOLN    
dextrose 70 % in water DEXTROSE IN WATER IV SOLN    
dietary supplement SCANDIBAR BAR PA Document  
dietary supplement SCANDISHAKE PACKET PA Document  
e-lytes/carboxymethylcellulose SALIVA SUBSTITUTE SOLUTION    
electrolyte solution,inj HYPERLYTE VIAL    
electrolyte solution,inj HYPERLYTE R VIAL    
electrolyte-148 solution MULTIPLE ELECTROLYTES T1 PH5.5 IV SOLN    
Electrolyte-2/Invert Sugar 5% TRAVERT-ELECTROLYTE NO.2 IV SOLN    
Electrolyte-4/Invert Sugar 5% TRAVERT-ELECTROLYTE NO.4 IV SOLN    
electrolyte-48 solution/D5W DEXTROSE 5%-ELECTROLYTE #48 IV SOLN    
Electrolyte-48/fructose 10 % FRUCTOSE-ELECTROLYTE NO.48 IV SOLN    
Electrolyte-48/fructose 5 % FRUCTOSE-ELECTROLYTE NO.48 IV SOLN    
electrolyte-75 solution/D5W DEXTROSE 5%-ELECTROLYTE #75 IV SOLN    
Electrolyte-75/fructose 5 % FRUCTOSE-ELECTROLYTE NO.75 IV SOLN    
electrolyte-A solution MULTIPLE ELECTROLYTES T1 PH7.4 IV SOLN    
electrolyte-A solution PLASMA-LYTE A PH 7.4 IV SOLN    
electrolyte-B solution/D50W DEXTROSE W/ELECTROLYTE B IV SOLN    
electrolyte-M solution/D5W NORMOSOL-M AND DEXTROSE IV SOLN    
electrolyte-M solution/D5W PLASMA-LYTE M IN DEXTROSE IV SOLN    
electrolyte-MB solution/D5W IONOSOL MB-DEXTROSE 5% IV SOLN    
electrolyte-P solution/D5W ISOLYTE P WITH DEXTROSE IV SOLN    
electrolyte-R (ph 7.4) NORMOSOL-R PH 7.4 IV SOLN    
electrolyte-R solution NORMOSOL-R IV SOLN    
electrolyte-R solution/D5W NORMOSOL-R AND DEXTROSE IV SOLN    
electrolyte-S (ph 7.4) ISOLYTE S IV SOLN    
electrolyte-S in 5 % dextrose ISOLYTE S WITH DEXTROSE IV SOLN    
electrolyte-S solution ISOLYTE S IV SOLN    
electrolytes/dextrose PEDIALYTE SOLUTION    
electrolytes/dextrose PEDIALYTE ELECTROLYTE SINGLES SOLUTION    
electrolytes/dextrose PEDIATRIC ELECTROLYTE SOLUTION    
electrolytes/dextrose TRUELYTE ADVANCED HYDRATION SOLUTION    
fructose 10 % FRUCTOSE IV SOLN    
intraventricular electrolytes1 INTRAVENTRICULAR ELECTROLYTES VIAL    
inverted sugar 10 % TRAVERT IV SOLN    
inverted sugar 10% in 0.9%NaCl TRAVERT IN NORMAL SALINE IV SOLN    
inverted sugar 5 % TRAVERT IV SOLN    
KCl in inverted sugar 10%-NaCl TRAVERT-1/2 NS WITH KCL IV SOLN    
lactose-reduced food COMPLETE NUTRITION PLUS LIQUID PA Document  
lactose-reduced food SCANDISHAKE PACKET PA Document  
Lytes/inverted sugar 10 % TRAVERT-ELECTROLYTE NO.1 IV SOLN    
Lytes/inverted sugar 10 % TRAVERT-ELECTROLYTE NO.2 IV SOLN    
Lytes/inverted sugar 10 % TRAVERT-ELECTROLYTE NO.3 IV SOLN    
magnesium carbonate/sod bicarb RENACARB TABLET DR    
magnesium chloride MAGNESIUM CHLORIDE VIAL    
magnesium sulfate MAGNESIUM SULFATE SYRINGE    
magnesium sulfate MAGNESIUM SULFATE VIAL    
magnesium sulfate in water MAGNESIUM SULFATE IV SOLN    
magnesium sulfate in water MAGNESIUM SULFATE PIGGYBACK    
magnesium sulfate/D5W MAGNESIUM SULFATE-D5W INFUS. BTL    
magnesium sulfate/D5W MAGNESIUM SULFATE-D5W PIGGYBACK    
manganese chloride MANGANESE CHLORIDE VIAL    
manganese chloride MANGANESE VIAL    
nutritional supplement REABILAN LIQUID PA Document  
nutritional supplement REABILANHN LIQUID PA Document  
nutritional supplement NUTREN 2.0 LIQUID PA Document  
nutritional supplement NUBASICS POWDER PA Document  
parent amino ac 5.2 % (renal) AMINOSYN-RF IV SOLN    
parent. amino acid 8.5 % no.3 AMINOSYN II IV SOLN    
parent.amino acid 10% no5(ped) AMINOSYN-PF IV SOLN    
parent.amino acid 7 % no1(ped) AMINOSYN-PF IV SOLN    
parenteral amino acid 10% no.1 AMINOSYN II IV SOLN    
parenteral amino acid 10% no.6 TRAVASOL IV SOLN    
parenteral amino acid 10% no.7 PREMASOL IV SOLN    
parenteral amino acid 15% no.1 NOVAMINE IV SOLN    
parenteral amino acid 15% no.2 AMINOSYN II IV SOLN    
parenteral amino acid 15% no.5 CLINISOL IV SOLN    
parenteral amino acid 15% no.6 PLENAMINE IV SOLN    
parenteral amino acid 20% no.1 PROSOL IV SOLN    
parenteral amino acid 7 % no.2 AMINOSYN II IV SOLN    
peri.dialysis soln28-ico 7.5 % EXTRANEAL ICODEXTRIN DIALYSIS IP SOLN    
perit. dialysis #21-dext 2.5 % DELFLEX WITH 2.5% DEXTROSE IP SOLN    
perit. dialysis #21-dext 2.5 % DELFLEX-2.5% DEXTROSE IP SOLN    
perit. dialysis 19-dextr 1.5 % DELFLEX WITH 1.5% DEXTROSE IP SOLN    
perit. dialysis 3-4.25 % dextr DIALYTE LM W/DEXTROSE 4.25% IP SOLN    
perit. dialysis 3-4.25 % dextr DIANEAL PD-2 W-4.25% DEXTROSE IP SOLN    
perit. dialysis no.6-1.5 % dex DELFLEX WITH 1.5% DEXTROSE IP SOLN    
perit. dialysis no.6-1.5 % dex DIANEAL WITH 1.5% DEXTROSE IP SOLN    
periton. dialysis 13-dex 2.5 % DIANEAL PD-2 W-2.5% DEXTROSE IP SOLN    
periton. dialysis 13-dex 2.5 % DIALYTE LM W/DEXTROSE 2.5% IP SOLN    
periton. dialysis 4-1.5 % dext DIANEAL PD-2 W-1.5% DEXTROSE IP SOLN    
periton. dialysis 4-1.5 % dext DIALYTE LM W/DEXTROSE 1.5% IP SOLN    
periton.dialysis 7-2.5 % dextr DELFLEX WITH 2.5% DEXTROSE IP SOLN    
periton.dialysis 7-2.5 % dextr DIANEAL WITH 2.5% DEXTROSE IP SOLN    
periton.dialysis 8-4.25 % dext DELFLEX WITH 4.25% DEXTROSE IP SOLN    
periton.dialysis 8-4.25 % dext DIANEAL WITH 4.25% DEXTROSE IP SOLN    
potassium acetate POTASSIUM ACETATE VIAL    
potassium chloride POTASSIUM CHLORIDE IV SOLN    
potassium chloride POTASSIUM CHLORIDE VIAL    
potassium chloride in 0.9%NaCl POTASSIUM CHLORIDE-0.9% NACL IV SOLN    
potassium chloride in 0.9%NaCl POTASSIUM CHL-NORMAL SALINE IV SOLN    
potassium chloride in D5W DEXTROSE 5%-POTASSIUM CHLORIDE IV SOLN    
potassium chloride in D5W POTASSIUM CHLORIDE-DEXTROSE 5% IV SOLN    
potassium chloride in LR-D5 POTASSIUM CHLORIDE IN D5LR IV SOLN    
potassium chloride in water POTASSIUM CHLORIDE PIGGYBACK    
potassium chloride-0.45% NaCl POTASSIUM CHLORIDE-0.45% NACL IV SOLN    
potassium chloride/D5-0.2%NaCl KCL-D5W-0.225% NACL IV SOLN    
potassium chloride/D5-0.2%NaCl DEXTROSE 5%-1/4NS-KCL IV SOLN    
potassium chloride/D5-0.2%NaCl KCL-D5W-0.2% NACL IV SOLN    
potassium chloride/D5-0.3%NaCl DEXTROSE 5%-1/3NS-KCL IV SOLN    
potassium chloride/D5-0.3%NaCl KCL-D5W-0.3% NACL IV SOLN    
potassium chloride/D5-0.45NaCl DEXTROSE 5%-1/2NS-KCL IV SOLN    
potassium chloride/D5-0.45NaCl KCL-D5W-0.45% NACL IV SOLN    
potassium chloride/D5-0.9%NaCl KCL-D5W-0.9% NACL IV SOLN    
potassium phos,m-basic-d-basic POTASSIUM PHOSPHATE VIAL    
potassium phos,m-basic-d-basic POTASSIUM PHOSPHATES VIAL    
Ringer's solution RINGERS INJECTION IV SOLN    
Ringer's solution,lactated LACTATED RINGERS IV SOLN    
selenium SELENIOUS ACID VIAL    
sod phosphate,monobasic-dibas SODIUM PHOSPHATE VIAL    
sodium acetate SODIUM ACETATE VIAL    
sodium bicarbonate SODIUM BICARBONATE IV SOLN    
sodium bicarbonate SODIUM BICARBONATE SYRINGE    
sodium bicarbonate SODIUM BICARBONATE VIAL    
sodium chloride SODIUM CHLORIDE SOLUTION    
sodium chloride SODIUM CHLORIDE TABLET SOL    
sodium chloride SODIUM CHLORIDE VIAL    
sodium chloride 0.325 % SODIUM CHLORIDE SYRINGE    
sodium chloride 0.45 % SODIUM CHLORIDE IV SOLN    
sodium chloride 0.45 % SODIUM CHLORIDE PGGYBK PRT    
sodium chloride 0.9 % (flush) SODIUM CHLORIDE SYRINGE    
sodium chloride 3 % SODIUM CHLORIDE IV SOLN    
sodium chloride 5 % SODIUM CHLORIDE IV SOLN    
sodium glycerophosphate GLYCOPHOS VIAL    
sodium lactate SODIUM LACTATE IV SOLN    
sodium polystyrene sulfonate SODIUM POLYSTYRENE SULFONATE POWDER    
sodium/pot/mag/calc/chlor/acet TPN ELECTROLYTES VIAL    
trace elements comb no.1 ADDAMEL N AMPUL    
triheptanoin DOJOLVI LIQUID PA Document  
tromethamine THAM IV SOLN    
vit C/Zn gluc/herbal no.325 ELDERBERRY ZINC LOZENGE    
zinc amino acid chelate ZINC CHELATED TABLET    
zinc chloride ZINC CHLORIDE VIAL    
zinc sulfate VERAZINC CAPSULE    
zinc sulfate ZINC SULFATE TABLET    
zinc sulfate ZINC SULFATE VIAL    
zinc/copper/manganese/selenium MULTRYS VIAL    
zinc/copper/manganese/selenium TRALEMENT VIAL    
Zn/Cu/mang/selen/fluor/pot iod PEDITRACE VIAL    
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