Potassium and K-Phos, 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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| potassium | POTASSIUM | TABLET | Y | N | ||
| potassium bicarbonate/cit ac | EFFER-K | TABLET EFF | Y | N | ||
| potassium chloride | POTASSIUM CHLORIDE | TAB ER PRT | Y | N | ||
| potassium chloride | KLOR-CON M15 | TAB ER PRT | Y | N | ||
| potassium chloride | KLOR-CON 8 | TABLET ER | Y | N | ||
| potassium phosphate,monobasic | PHOSPHO-TRIN K500 | TABLET SOL | Y | N | ||
| sod phos di, mono/K phos mono | WES-PHOS 250 NEUTRAL | TABLET | Y | N | ||
| sod phos di, mono/K phos mono | PHOSPHO-TRIN 250 NEUTRAL | TABLET | Y | N | ||
| potassium bicarbonate/cit ac | EFFER-K | TABLET EFF | N | N | ||
| potassium chloride | POTASSIUM CHLORIDE | LIQUID | N | N | ||
| potassium chloride | KAOCHLOR | LIQUID | N | N | ||
| potassium chloride | K-LOR | PACKET | N | N | ||
| potassium chloride | KLOR-CON | PACKET | N | N | ||
| potassium chloride | K-VESCENT | PACKET | N | N | ||
| potassium chloride | POTASSIUM CHLORIDE | TABLET ER | N | N | ||
| potassium gluconate | KAON | ELIXIR | N | N |