Antidiarrheals
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 |
|---|---|---|---|---|---|---|
| loperamide HCl | ANTI-DIARRHEAL | CAPSULE | Y | Quantity Limit | N | |
| loperamide HCl | LOPERAMIDE | LIQUID | Y | Quantity Limit | N | |
| loperamide HCl | LOPERAMIDE HCL | LIQUID | Y | Quantity Limit | N | |
| loperamide HCl | ANTI-DIARRHEAL | LIQUID | Y | Quantity Limit | N | |
| loperamide HCl | ANTI-DIARRHEAL | TABLET | Y | Quantity Limit | N | |
| loperamide HCl | LOPERAMIDE | TABLET | Y | Quantity Limit | N | |
| loperamide HCl | ULTRA A-D | TABLET | Y | Quantity Limit | N | |
| loperamide HCl | IMODIUM A-D | TABLET | Y | Quantity Limit | N | |
| loperamide HCl | ANTI-DIARRHEAL | TABLET | Y | Quantity Limit | N | |
| loperamide HCl | LOPERAMIDE HCL | TABLET | Y | Quantity Limit | N | |
| alosetron HCl | LOTRONEX | TABLET | N | Pharmacy PA | N | |
| bismuth subsalicylate | PINK BISMUTH | ORAL SUSP | N | N | ||
| bismuth subsalicylate | STOMACH RELIEF | TAB CHEW | N | N | ||
| bismuth subsalicylate | PINK BISMUTH | TABLET | N | N | ||
| diphenoxylate HCl/atropine | DIPHENOXYLATE-ATROPINE | LIQUID | N | N | ||
| diphenoxylate HCl/atropine | DIPHENOXYLATE-ATROPINE | TABLET | N | N | ||
| diphenoxylate HCl/atropine | LOMOTIL | TABLET | N | N | ||
| loperamide HCl/simethicone | ANTI-DIARRHEAL-ANTI-GAS | TABLET | N | Quantity Limit | N | |
| opium tincture | OPIUM TINCTURE | TINCTURE | N | N |