Misc Antibiotics

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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
clindamycin phosphate CLINDAMYCIN PHOSPHATE GEL DAILY N    
clindamycin phosphate CLINDAGEL GEL DAILY N    
aztreonam AZACTAM VIAL    
aztreonam AZTREONAM VIAL    
aztreonam/dextrose-water AZACTAM-ISO-OSMOTIC DEXTROSE FROZ.PIGGY    
bacitracin BACIIM VIAL    
bacitracin BACI-IM VIAL    
bacitracin BACITRACIN VIAL    
ciprofloxacin in 5 % dextrose CIPRO I.V. PIGGYBACK    
ciprofloxacin in 5 % dextrose CIPROFLOXACIN-D5W PIGGYBACK    
ciprofloxacin lactate CIPRO I.V. VIAL    
ciprofloxacin lactate CIPROFLOXACIN VIAL    
clindamycin HCl CLEOCIN HCL CAPSULE    
clindamycin HCl CLINDAMYCIN HCL CAPSULE    
clindamycin in 0.9 % sod chlor CLINDAMYCIN-0.9% NACL PIGGYBACK    
clindamycin palmitate HCl CLINDAMYCIN PALMITATE HCL SOLN RECON    
clindamycin palmitate HCl CLEOCIN PALMITATE SOLN RECON    
clindamycin palmitate HCl CLINDAMYCIN PEDIATRIC SOLN RECON    
clindamycin phosphate CLINDAMYCIN PHOSPHATE VIAL    
clindamycin phosphate CLEOCIN PHOSPHATE VIAL    
clindamycin phosphate CLINDAMYCIN PHOSPHATE VIAL PORT    
clindamycin phosphate CLEOCIN PHOSPHATE VIAL PORT    
clindamycin phosphate/D5W CLEOCIN PHOSPHATE IN D5W PIGGYBACK    
clindamycin phosphate/D5W CLINDAMYCIN PHOSPHATE-D5W PIGGYBACK    
colistin (colistimethate Na) COLY-MYCIN M PARENTERAL VIAL    
colistin (colistimethate Na) COLISTIMETHATE VIAL    
dalbavancin HCl DALVANCE VIAL    
daptomycin DAPTOMYCIN VIAL    
daptomycin CUBICIN VIAL    
daptomycin CUBICIN RF VIAL    
delafloxacin meglumine BAXDELA VIAL    
doripenem DORIPENEM VIAL    
ertapenem sodium INVANZ VIAL    
ertapenem sodium ERTAPENEM VIAL    
imipenem/cilastatin sodium PRIMAXIN VIAL    
imipenem/cilastatin sodium IMIPENEM-CILASTATIN SODIUM VIAL    
lincomycin HCl LINCOMYCIN HCL VIAL    
lincomycin HCl LINCOCIN VIAL    
lincomycin HCl LINCOJECT VIAL    
linezolid in dextrose 5% ZYVOX PIGGYBACK    
linezolid in dextrose 5% LINEZOLID-D5W PIGGYBACK    
linezolid-0.9% sodium chloride LINEZOLID-0.9% NACL PIGGYBACK    
meropenem MERREM INFUS. BTL    
meropenem MERREM VIAL    
meropenem MEROPENEM VIAL    
meropenem MERREM VIAL PORT    
meropenem-0.9% sodium chloride MEROPENEM-0.9% NACL PIGGYBACK    
meropenem/vaborbactam VABOMERE VIAL    
moxifloxacin-sod.chloride(iso) MOXIFLOXACIN PIGGYBACK    
moxifloxacin-sod.chloride(iso) AVELOX IV PIGGYBACK    
moxifloxacin/sod.ace,sul/water MOXIFLOXACIN PIGGYBACK    
oritavancin diphosphate ORBACTIV VIAL    
polymyxin B sulfate POLYMYXIN B SULFATE VIAL    
quinupristin/dalfopristin SYNERCID VIAL    
rifabutin RIFABUTIN CAPSULE    
rifabutin MYCOBUTIN CAPSULE    
rifaximin XIFAXAN TABLET PA Document May 28, 2015
tedizolid phosphate SIVEXTRO VIAL    
telavancin HCl VIBATIV VIAL    
thalidomide THALOMID CAPSULE    
tigecycline TIGECYCLINE VIAL    
tigecycline TYGACIL VIAL