Hyoscyamine
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 | New Drug Evaluation |
|---|---|---|---|---|---|
| hyoscyamine sulfate | HYOSCYAMINE SULFATE | ELIXIR | Y | ||
| hyoscyamine sulfate | ED-SPAZ | TAB RAPDIS | Y | ||
| hyoscyamine sulfate | HYOSCYAMINE SULFATE | TAB RAPDIS | Y | ||
| hyoscyamine sulfate | NULEV | TAB RAPDIS | Y | ||
| hyoscyamine sulfate | HYOSCYAMINE SULFATE | DROPS | N | ||
| hyoscyamine sulfate | HYOSCYAMINE SULFATE ER | TAB ER 12H | N | ||
| hyoscyamine sulfate | HYOSCYAMINE SULFATE | TAB ER 12H | N | ||
| hyoscyamine sulfate | MAR-SPAS | TAB RAPDIS | N | ||
| hyoscyamine sulfate | OSCIMIN | TABLET | N | ||
| hyoscyamine sulfate | DONNAMAR | TABLET | N | ||
| hyoscyamine sulfate | HYOSCYAMINE SULFATE | TABLET | N | ||
| hyoscyamine sulfate | LEVSIN | TABLET | N | ||
| hyoscyamine sulfate | HYOSCYAMINE SULFATE | TAB SUBL | |||
| hyoscyamine sulfate | LEVSIN-SL | TAB SUBL | |||
| hyoscyamine sulfate | OSCIMIN SL | TAB SUBL |