Antifungals, Parenteral
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 |
|---|---|---|---|---|---|---|
| isavuconazonium sulfate | CRESEMBA | VIAL | N | N | ||
| amphotericin B | AMPHOTERICIN B | VIAL | N | |||
| amphotericin B liposome | AMBISOME | VIAL | N | |||
| amphotericin B liposome | AMPHOTERICIN B LIPOSOME | VIAL | N | |||
| anidulafungin | ERAXIS | VIAL | N | |||
| caspofungin acetate | CASPOFUNGIN ACETATE | VIAL | N | |||
| fluconazole in NaCL,iso-osm | FLUCONAZOLE IN SALINE | PIGGYBACK | N | |||
| fluconazole in NaCL,iso-osm | FLUCONAZOLE-NACL | PIGGYBACK | N | |||
| micafungin in 0.9 % sodium chl | MICAFUNGIN-0.9% NACL | PIGGYBACK | N | |||
| micafungin sodium | MYCAMINE | VIAL | N | |||
| micafungin sodium | MICAFUNGIN | VIAL | N | |||
| posaconazole | NOXAFIL | VIAL | N | |||
| posaconazole | POSACONAZOLE | VIAL | N | |||
| rezafungin acetate | REZZAYO | VIAL | N | |||
| voriconazole | VFEND IV | VIAL | N | |||
| voriconazole | VORICONAZOLE | VIAL | N | |||
| voriconazole/HPBCD | VORICONAZOLE (HPBCD) | VIAL | N |