Fluoroquinolones, Oral
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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 & Updates |
|---|---|---|---|---|---|
| ciprofloxacin | CIPRO | SUS MC REC | Y | ||
| ciprofloxacin | CIPROFLOXACIN | SUS MC REC | Y | ||
| ciprofloxacin HCl | CIPRO | TABLET | Y | ||
| ciprofloxacin HCl | CIPROFLOXACIN HCL | TABLET | Y | ||
| levofloxacin | LEVOFLOXACIN | SOLUTION | Y | ||
| levofloxacin | LEVOFLOXACIN | TABLET | Y | ||
| moxifloxacin HCl | MOXIFLOXACIN HCL | TABLET | Y | ||
| ciprofloxacin/ciprofloxa HCl | CIPRO XR | TBMP 24HR | N | ||
| delafloxacin meglumine | BAXDELA | TABLET | N | ||
| lomefloxacin HCl | MAXAQUIN | TABLET | N | ||
| ofloxacin | OFLOXACIN | TABLET | N |