Cephalosporins, Parenteral

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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
cefamandole in dextrose 5 % MANDOL IN DEXTROSE PIGGYBACK    
cefazolin sodium CEFAZOLIN SODIUM VIAL    
cefazolin sodium ANCEF VIAL    
cefazolin sodium CEFAZOLIN SODIUM VIAL PORT    
cefazolin sodium/dextrose,iso CEFAZOLIN SODIUM-DEXTROSE FROZ.PIGGY    
cefazolin sodium/dextrose,iso CEFAZOLIN SODIUM-DEXTROSE PIGGYBACK    
cefepime HCl CEFEPIME HCL VIAL    
cefepime HCl MAXIPIME VIAL    
cefepime HCl MAXIPIME VIAL PORT    
cefepime HCl in dextrose 5 % CEFEPIME-DEXTROSE PIGGYBACK    
cefepime in iso-osm dextrose CEFEPIME FROZ.PIGGY    
cefotaxime sodium CEFOTAXIME SODIUM VIAL    
cefotaxime sodium CLAFORAN VIAL    
cefotaxime sodium CLAFORAN VIAL PORT    
cefotaxime sodium/dextrose,iso CLAFORAN-DEXTROSE FROZ.PIGGY    
cefotetan disod/isosm dextrose CEFOTETAN & DEXTROSE PIGGYBACK    
cefotetan disodium CEFOTETAN VIAL    
cefotetan disodium CEFOTAN VIAL    
cefoxitin sodium CEFOXITIN VIAL    
cefoxitin sodium/D5W MEFOXIN FROZ.PIGGY    
cefoxitin sodium/dextrose,iso CEFOXITIN SODIUM PIGGYBACK    
ceftaroline fosamil acetate TEFLARO VIAL    
ceftazidime CEFTAZIDIME VIAL    
ceftazidime FORTAZ VIAL    
ceftazidime TAZICEF VIAL    
ceftazidime FORTAZ VIAL PORT    
ceftazidime TAZICEF VIAL PORT    
ceftazidime in dextrose5%water CEFTAZIDIME PIGGYBACK    
ceftazidime-dextrose (iso-osm) TAZICEF IN DEXTROSE FROZ.PIGGY    
ceftazidime/avibactam AVYCAZ VIAL    
ceftolozane/tazobactam ZERBAXA VIAL    
ceftriaxone in is-osm dextrose CEFTRIAXONE FROZ.PIGGY    
ceftriaxone in is-osm dextrose CEFTRIAXONE PIGGYBACK    
ceftriaxone sodium CEFTRIAXONE VIAL    
ceftriaxone sodium CEFTRIAXONE VIAL PORT    
cefuroxime sodium CEFUROXIME SODIUM VIAL    
cefuroxime sodium ZINACEF VIAL    
cefuroxime sodium/D5W ZINACEF PIGGYBACK    
cephapirin sodium CEFADYL VIAL