Misc Antibiotics
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 |
|---|---|---|---|---|---|---|
| sulopenem etzadroxl/probenecid | ORLYNVAH | TABLET | N | Aug 07, 2025 | ||
| aztreonam | AZACTAM | VIAL | ||||
| aztreonam | AZTREONAM | VIAL | ||||
| aztreonam/avibactam sodium | EMBLAVEO | VIAL | ||||
| bacitracin | BACI-IM | VIAL | ||||
| ciprofloxacin in 5 % dextrose | CIPROFLOXACIN-D5W | PIGGYBACK | ||||
| ciprofloxacin lactate | CIPRO I.V. | 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 | CLEOCIN PEDIATRIC | SOLN RECON | ||||
| clindamycin palmitate HCl | CLINDAMYCIN (PEDIATRIC) | SOLN RECON | ||||
| clindamycin phosphate | CLEOCIN PHOSPHATE | VIAL | ||||
| clindamycin phosphate | CLINDAMYCIN PHOSPHATE | VIAL | ||||
| clindamycin phosphate/D5W | CLINDAMYCIN PHOSPHATE-D5W | PGGYBK BTL | ||||
| clindamycin phosphate/D5W | CLINDAMYCIN PHOSPHATE-D5W | PIGGYBACK | ||||
| colistin (colistimethate Na) | COLY-MYCIN M PARENTERAL | VIAL | ||||
| colistin (colistimethate Na) | COLISTIMETHATE | VIAL | ||||
| dalbavancin HCl | DALBAVANCIN HCL | VIAL | ||||
| dalbavancin HCl | DALVANCE | VIAL | ||||
| daptomycin | DAPTOMYCIN | VIAL | ||||
| daptomycin in 0.9 % sod chlor | DAPTOMYCIN-0.9% NACL | FROZ.PIGGY | ||||
| delafloxacin meglumine | BAXDELA | VIAL | ||||
| durlobactam sodium | DURLOBACTAM (XACDURO) | VIAL | ||||
| ertapenem sodium | ERTAPENEM | VIAL | ||||
| imipenem/cilastatin sodium | PRIMAXIN | VIAL | ||||
| imipenem/cilastatin sodium | IMIPENEM-CILASTATIN SODIUM | VIAL | ||||
| imipenem/cilastatin/relebactam | RECARBRIO | VIAL | ||||
| lincomycin HCl | LINCOCIN | VIAL | ||||
| lincomycin HCl | LINCOJECT | VIAL | ||||
| lincomycin HCl | LINCOMYCIN HCL | VIAL | ||||
| linezolid in 0.9% sodium chlor | LINEZOLID-0.9% NACL | PIGGYBACK | ||||
| linezolid in dextrose 5% | ZYVOX | PIGGYBACK | ||||
| linezolid in dextrose 5% | LINEZOLID-D5W | PIGGYBACK | ||||
| meropenem | MERREM | INFUS. BTL | ||||
| 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.ace,sul/water | MOXIFLOXACIN | PIGGYBACK | ||||
| oritavancin diphosphate | KIMYRSA | VIAL | ||||
| oritavancin diphosphate | ORBACTIV | VIAL | ||||
| polymyxin B sulfate | POLYMYXIN B SULFATE | VIAL | ||||
| sulbactam sod/durlobactam sod | XACDURO | VIAL | ||||
| sulbactam sodium | SULBACTAM (XACDURO) | VIAL | ||||
| tedizolid phosphate | SIVEXTRO | VIAL | ||||
| telavancin HCl | VIBATIV | VIAL | ||||
| thalidomide | THALOMID | CAPSULE | ||||
| tigecycline | TIGECYCLINE | VIAL | ||||
| tigecycline | TYGACIL | VIAL |