Antiemetics, Conventional
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 |
|---|---|---|---|---|---|---|
| metoclopramide HCl | METOCLOPRAMIDE HCL INTENSOL | ORAL CONC | Y | |||
| metoclopramide HCl | METOCLOPRAMIDE HCL | SOLUTION | Y | |||
| metoclopramide HCl | REGLAN | TABLET | Y | |||
| metoclopramide HCl | METOCLOPRAMIDE HCL | TABLET | Y | |||
| phosphorated carbo(dext-fruct) | ANTI-NAUSEA | SOLUTION | Y | |||
| phosphorated carbo(dext-fruct) | NAUSEA RELIEF | SOLUTION | Y | |||
| phosphorated carbo(dext-fruct) | ANTI-NAUSEA | SOLUTION | Y | |||
| phosphorated carbo(dext-fruct) | EMETROL | SOLUTION | Y | |||
| phosphorated carbo(dext-fruct) | ESPECOL | SOLUTION | Y | |||
| phosphorated carbo(dext-fruct) | NAUSEA CONTROL | SOLUTION | Y | |||
| phosphorated carbo(dext-fruct) | NAUSEA RELIEF | SOLUTION | Y | |||
| prochlorperazine | COMPRO | SUPP.RECT | Y | |||
| prochlorperazine edisylate | COMPAZINE | SYRUP | Y | |||
| prochlorperazine maleate | PROCHLORPERAZINE MALEATE | TABLET | Y | |||
| prochlorperazine maleate | PROCHLORPERAZINE | TABLET | Y | |||
| promethazine HCl | PROMETHAZINE HCL | SUPP.RECT | Y | |||
| promethazine HCl | PROMETHAZINE HCL | SYRUP | Y | |||
| promethazine HCl | PROMETHAZINE HCL | TABLET | Y | |||
| dimenhydrinate | DRIMINATE | TABLET | N | Pharmacy PA | ||
| dimenhydrinate | MOTION SICKNESS | TABLET | N | Pharmacy PA | ||
| dimenhydrinate | MOTION SICKNESS RELIEF | TABLET | N | Pharmacy PA | ||
| dronabinol | DRONABINOL | CAPSULE | N | Pharmacy PA | ||
| dronabinol | MARINOL | CAPSULE | N | Pharmacy PA | ||
| meclizine HCl | ANTIVERT | TAB CHEW | N | Pharmacy PA | ||
| meclizine HCl | MOTION SICKNESS | TAB CHEW | N | Pharmacy PA | ||
| meclizine HCl | MOTION SICKNESS RELIEF | TAB CHEW | N | Pharmacy PA | ||
| meclizine HCl | MOTION-TIME | TAB CHEW | N | Pharmacy PA | ||
| meclizine HCl | TRAVEL EASE | TAB CHEW | N | Pharmacy PA | ||
| meclizine HCl | MECLIZINE HCL | TAB CHEW | N | Pharmacy PA | ||
| meclizine HCl | MECLIZINE HCL | TABLET | N | Pharmacy PA | ||
| meclizine HCl | MOTION SICKNESS | TABLET | N | Pharmacy PA | ||
| meclizine HCl | MOTION SICKNESS RELIEF | TABLET | N | Pharmacy PA | ||
| metoclopramide HCl | GIMOTI | SPRAY/PUMP | N | Pharmacy PA | ||
| scopolamine | SCOPOLAMINE | PATCH TD 3 | N | Pharmacy PA | ||
| scopolamine | TRANSDERM-SCOP | PATCH TD 3 | N | Pharmacy PA | ||
| trimethobenzamide HCl | TRIMETHOBENZAMIDE HCL | CAPSULE | N | Pharmacy PA | ||
| dimenhydrinate | DIMENHYDRINATE | VIAL | ||||
| meclizine HCl | ANTIVERT | TABLET | ||||
| meclizine HCl | MECLIZINE HCL | TABLET | ||||
| metoclopramide HCl | METOCLOPRAMIDE HCL | SYRINGE | ||||
| metoclopramide HCl | METOCLOPRAMIDE HCL | VIAL | ||||
| prochlorperazine edisylate | COMPAZINE | VIAL | ||||
| prochlorperazine edisylate | PROCHLORPERAZINE EDISYLATE | VIAL | ||||
| promethazine HCl | PHENERGAN | AMPUL | ||||
| promethazine HCl | PROMETHAZINE HCL | AMPUL | ||||
| promethazine HCl | PHENERGAN | VIAL | ||||
| promethazine HCl | PROMETHAZINE HCL | VIAL | ||||
| promethazine HCl | ANERGAN 50 | VIAL | ||||
| trimethobenzamide HCl | TIGAN | VIAL |