Macrolides, Oral
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 | New Drug Evaluation |
|---|---|---|---|---|---|
| azithromycin | ZITHROMAX | SUSP RECON | Y | ||
| azithromycin | AZITHROMYCIN | SUSP RECON | Y | ||
| azithromycin | ZITHROMAX TRI-PAK | TABLET | Y | ||
| azithromycin | ZITHROMAX | TABLET | Y | ||
| azithromycin | AZITHROMYCIN | TABLET | Y | ||
| clarithromycin | CLARITHROMYCIN | TABLET | Y | ||
| azithromycin | AZITHROMYCIN | PACKET | N | ||
| azithromycin | ZITHROMAX | PACKET | N | ||
| clarithromycin | CLARITHROMYCIN | SUSP RECON | N | ||
| clarithromycin | CLARITHROMYCIN ER | TAB ER 24H | N | ||
| erythromycin base | ERYTHROMYCIN BASE | CAPSULE DR | N | ||
| erythromycin base | ERYTHROMYCIN | CAPSULE DR | N | ||
| erythromycin base | ERYTHROMYCIN | TABLET | N | ||
| erythromycin base | ERYTHROMYCIN | TABLET DR | N | ||
| erythromycin base | ERY-TAB | TABLET DR | N | ||
| erythromycin ethylsuccinate | E.E.S. 200 | SUSP RECON | N | ||
| erythromycin ethylsuccinate | ERYPED 200 | SUSP RECON | N | ||
| erythromycin ethylsuccinate | ERYPED 400 | SUSP RECON | N | ||
| erythromycin ethylsuccinate | ERYTHROMYCIN ETHYLSUCCINATE | SUSP RECON | N | ||
| erythromycin ethylsuccinate | E.E.S. 400 | TABLET | N | ||
| erythromycin ethylsuccinate | ERYTHROMYCIN ETHYLSUCCINATE | TABLET | N | ||
| erythromycin stearate | ERYTHROCIN STEARATE | TABLET | N |