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
Status
Current Drug Use Criteria New Drug Evaluation
aztreonam AZACTAM VIAL    
aztreonam AZTREONAM VIAL    
bacitracin BACI-IM VIAL    
bacitracin BACITRACIN 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 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    
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 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