Mycobacterium drugs
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 | New Drug Evaluation |
|---|---|---|---|---|---|
| bedaquiline fumarate | SIRTURO | TABLET | Jan 30, 2014 | ||
| cycloserine | CYCLOSERINE | CAPSULE | |||
| ethambutol HCl | MYAMBUTOL | TABLET | |||
| ethambutol HCl | ETHAMBUTOL HCL | TABLET | |||
| ethionamide | TRECATOR | TABLET | |||
| isoniazid | ISONIAZID | SOLUTION | |||
| isoniazid | ISONIAZID | TABLET | |||
| pretomanid | PRETOMANID | TABLET | |||
| pyrazinamide | PYRAZINAMIDE | TABLET | |||
| rifabutin | RIFABUTIN | CAPSULE | |||
| rifabutin | MYCOBUTIN | CAPSULE | |||
| rifampin | RIFAMPIN | CAPSULE | |||
| rifapentine | PRIFTIN | TABLET |