Penicillin
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 |
|---|---|---|---|---|---|---|
| pivmecillinam HCl | PIVYA | TABLET | N | N | Aug 07, 2025 | |
| amoxicillin | AMOXICILLIN | CAPSULE | N | |||
| amoxicillin | AMOXICILLIN | SUSP RECON | N | |||
| amoxicillin | AMOXICILLIN | TAB CHEW | N | |||
| amoxicillin | AMOXICILLIN | TABLET | N | |||
| ampicillin sod/sulbactam sod | UNASYN | VIAL | N | |||
| ampicillin sod/sulbactam sod | AMPICILLIN-SULBACTAM | VIAL | N | |||
| ampicillin sod/sulbactam sod | AMPICILLIN-SULBACTAM | VIAL PORT | N | |||
| ampicillin sodium | AMPICILLIN SODIUM | VIAL | N | |||
| ampicillin sodium | AMPICILLIN SODIUM | VIAL PORT | N | |||
| ampicillin trihydrate | AMPICILLIN TRIHYDRATE | CAPSULE | N | |||
| dicloxacillin sodium | DICLOXACILLIN SODIUM | CAPSULE | N | |||
| nafcillin in dextrose,iso-osm | NAFCILLIN | FROZ.PIGGY | N | |||
| nafcillin in dextrose,iso-osm | NALLPEN-ISO-OSMOTIC DEXTROSE | FROZ.PIGGY | N | |||
| nafcillin sodium | NAFCILLIN SODIUM | VIAL | N | |||
| nafcillin sodium/D5W | NALLPEN IN DEXTROSE | PIGGYBACK | N | |||
| nafcillin sodium/D5W | NAFCILL IN DEXTROSE | PIGGYBACK | N | |||
| oxacillin in dextrose(iso-osm) | OXACILLIN | FROZ.PIGGY | N | |||
| oxacillin sodium | OXACILLIN SODIUM | VIAL | N | |||
| pen G benz/pen G procaine | BICILLIN C-R | SYRINGE | N | |||
| pen G pot/dextrose-water | PENICILLIN GK-ISO-OSM DEXTROSE | FROZ.PIGGY | N | |||
| penicillin G benzathine | BICILLIN L-A | SYRINGE | N | |||
| penicillin G benzathine | EXTENCILLINE | VIAL | N | |||
| penicillin G potassium | PFIZERPEN | VIAL | N | |||
| penicillin G potassium | PENICILLIN G POTASSIUM | VIAL | N | |||
| penicillin G potassium/D5W | PENICILLIN G POTASSIUM IN D5W | PIGGYBACK | N | |||
| penicillin G sodium | PENICILLIN G SODIUM | VIAL | N | |||
| penicillin V potassium | PENICILLIN V POTASSIUM | SOLN RECON | N | |||
| penicillin V potassium | PENICILLIN V POTASSIUM | TABLET | N | |||
| piperacillin sodium | PIPRACIL | VIAL | N | |||
| piperacillin sodium/D5W | PIPRACIL IN DEXTROSE | PIGGYBACK | N | |||
| piperacillin sodium/tazobactam | PIPERACILLIN-TAZOBACTAM | PIGGYBACK | N | |||
| piperacillin sodium/tazobactam | PIPERACILLIN-TAZOBACTAM | VIAL | N | |||
| piperacillin sodium/tazobactam | PIPERACILLIN-TAZOBACTAM | VIAL PORT | N | |||
| piperacillin-tazo-dextrose,iso | ZOSYN | FROZ.PIGGY | N | |||
| ticarcillin disodium/D5W | TICAR IN DEXTROSE | PIGGYBACK | N |