Hyoscyamine

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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 but eligible patients will encounter a co-pay at the pharmacy.
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 New Drug Evaluation
hyoscyamine sulfate HYOSCYAMINE SULFATE ELIXIR Y    
hyoscyamine sulfate NULEV TAB RAPDIS Y    
hyoscyamine sulfate OSCIMIN TAB RAPDIS Y    
hyoscyamine sulfate ANASPAZ TAB RAPDIS Y    
hyoscyamine sulfate ED-SPAZ TAB RAPDIS Y    
hyoscyamine sulfate HYOSCYAMINE SULFATE TAB RAPDIS Y    
hyoscyamine sulfate HYOSCYAMINE SULFATE DROPS N    
hyoscyamine sulfate SYMAX-SR TAB ER 12H N    
hyoscyamine sulfate OSCIMIN SR TAB ER 12H N    
hyoscyamine sulfate HYOSCYAMINE SULFATE TAB ER 12H N    
hyoscyamine sulfate HYOSCYAMINE SULFATE ER TAB ER 12H N    
hyoscyamine sulfate LEVBID TAB ER 12H N    
hyoscyamine sulfate SYMAX DUOTAB TAB MPHASE N    
hyoscyamine sulfate MAR-SPAS TAB RAPDIS N    
hyoscyamine sulfate OSCIMIN TABLET N    
hyoscyamine sulfate LEVSIN TABLET N    
hyoscyamine sulfate DONNAMAR TABLET N    
hyoscyamine sulfate HYOSCYAMINE SULFATE TABLET N    
hyoscyamine sulfate LEVSIN AMPUL    
hyoscyamine sulfate LEVSIN-SL TAB SUBL    
hyoscyamine sulfate OSCIMIN SL TAB SUBL    
hyoscyamine sulfate HYOSCYAMINE SULFATE TAB SUBL