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.
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
Current Drug Use Criteria New Drug Evaluation
lefamulin acetate XENLETA TABLET N   Feb 06, 2020
aztreonam AZTREONAM VIAL    
aztreonam AZACTAM VIAL    
bacitracin BACITRACIN VIAL    
bacitracin BACI-IM VIAL    
ciprofloxacin in 5 % dextrose CIPROFLOXACIN-D5W PIGGYBACK    
ciprofloxacin lactate CIPRO I.V. VIAL    
clindamycin HCl CLEOCIN 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    
colistin (colistimethate Na) COLISTIMETHATE VIAL    
colistin (colistimethate Na) COLY-MYCIN M PARENTERAL VIAL    
dalbavancin HCl DALVANCE VIAL    
daptomycin CUBICIN RF VIAL    
daptomycin DAPTOMYCIN VIAL    
daptomycin in 0.9 % sod chlor DAPTOMYCIN-0.9% NACL FROZ.PIGGY    
delafloxacin meglumine BAXDELA VIAL    
ertapenem sodium ERTAPENEM VIAL    
imipenem/cilastatin sodium PRIMAXIN VIAL    
imipenem/cilastatin sodium IMIPENEM-CILASTATIN SODIUM VIAL    
imipenem/cilastatin/relebactam RECARBRIO VIAL    
lefamulin acetate XENLETA VIAL   Feb 06, 2020
lincomycin HCl LINCOMYCIN HCL VIAL    
lincomycin HCl LINCOJECT VIAL    
lincomycin HCl LINCOCIN 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 ORBACTIV VIAL    
oritavancin diphosphate KIMYRSA VIAL    
polymyxin B sulfate POLYMYXIN B SULFATE VIAL    
tedizolid phosphate SIVEXTRO VIAL    
telavancin HCl VIBATIV VIAL    
thalidomide THALOMID CAPSULE    
tigecycline TIGECYCLINE VIAL    
tigecycline TYGACIL VIAL