Clostridioides difficile Drugs
PDL Reference Documents
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| metronidazole | METRONIDAZOLE | TABLET | Y | N | ||
| metronidazole | FLAGYL | TABLET | Y | N | ||
| vancomycin HCl | VANCOCIN HCL | CAPSULE | Y | N | ||
| vancomycin HCl | VANCOMYCIN HCL | CAPSULE | Y | N | ||
| vancomycin HCl | VANCOMYCIN HCL | VIAL | Y | N | ||
| bezlotoxumab | ZINPLAVA | VIAL | N | Pharmacy PA | N | |
| fecal microbio spore,live-brpk | VOWST | CAPSULE | N | Pharmacy PA | N | Aug 03, 2023 |
| fecal microbiota, live-jslm | REBYOTA | ENEMA | N | Pharmacy PA | N | |
| fidaxomicin | DIFICID | SUSP RECON | N | Pharmacy PA | N | |
| fidaxomicin | DIFICID | TABLET | N | Pharmacy PA | N | Apr 26, 2012 |
| fidaxomicin | FIDAXOMICIN | TABLET | N | Pharmacy PA | N | |
| metronidazole | METRONIDAZOLE | CAPSULE | N | N | ||
| metronidazole | LIKMEZ | ORAL SUSP | N | N | ||
| metronidazole | METRONIDAZOLE | TABLET | N | N | ||
| vancomycin HCl | FIRVANQ | SOLN RECON | N | N | ||
| vancomycin HCl | VANCOMYCIN HCL | SOLN RECON | N | N | ||
| vancomycin HCl | VANCOMYCIN HCL | VIAL | N | N |