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 | N | ||
| metoclopramide HCl | METOCLOPRAMIDE HCL | SOLUTION | Y | N | ||
| phosphorated carbo(dext-fruct) | ANTI-NAUSEA | SOLUTION | Y | N | ||
| phosphorated carbo(dext-fruct) | ANTI-NAUSEA | SOLUTION | Y | N | ||
| phosphorated carbo(dext-fruct) | NAUSEA CONTROL | SOLUTION | Y | N | ||
| phosphorated carbo(dext-fruct) | EMETROL | SOLUTION | Y | N | ||
| prochlorperazine | COMPRO | SUPP.RECT | Y | N | ||
| prochlorperazine maleate | PROCHLORPERAZINE | TABLET | Y | N | ||
| promethazine HCl | PROMETHAZINE HCL | SYRUP | Y | N | ||
| dimenhydrinate | MOTION SICKNESS RELIEF | TABLET | N | Pharmacy PA | N | |
| dimenhydrinate | DRIMINATE | TABLET | N | Pharmacy PA | N | |
| dronabinol | MARINOL | CAPSULE | N | Pharmacy PA | N | |
| meclizine HCl | TRAVEL EASE | TAB CHEW | N | Pharmacy PA | N | |
| meclizine HCl | MOTION SICKNESS | TAB CHEW | N | Pharmacy PA | N | |
| meclizine HCl | MOTION SICKNESS RELIEF | TAB CHEW | N | Pharmacy PA | N | |
| meclizine HCl | MOTION-TIME | TAB CHEW | N | Pharmacy PA | N | |
| meclizine HCl | ANTIVERT | TAB CHEW | N | Pharmacy PA | N | |
| meclizine HCl | MOTION SICKNESS RELIEF | TABLET | N | Pharmacy PA | N | |
| scopolamine | TRANSDERM-SCOP | PATCH TD 3 | N | Pharmacy PA | N | |
| trimethobenzamide HCl | TRIMETHOBENZAMIDE HCL | CAPSULE | N | Pharmacy PA | N | |
| meclizine HCl | ANTIVERT | TABLET | N | |||
| metoclopramide HCl | METOCLOPRAMIDE HCL | SYRINGE | N | |||
| prochlorperazine edisylate | COMPAZINE | VIAL | N | |||
| promethazine HCl | PROMETHAZINE HCL | AMPUL | N | |||
| promethazine HCl | PROMETHAZINE HCL | VIAL | N |