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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
sulopenem etzadroxl/probenecid ORLYNVAH TABLET N   N Aug 07, 2025
aztreonam AZACTAM VIAL   N  
aztreonam AZTREONAM VIAL   N  
aztreonam/avibactam sodium EMBLAVEO VIAL   N  
bacitracin BACI-IM VIAL   N  
ciprofloxacin in 5 % dextrose CIPROFLOXACIN-D5W PIGGYBACK   N  
ciprofloxacin lactate CIPRO I.V. VIAL   N  
clindamycin HCl CLEOCIN HCL CAPSULE   N  
clindamycin HCl CLINDAMYCIN HCL CAPSULE   N  
clindamycin in 0.9 % sod chlor CLINDAMYCIN-0.9% NACL PIGGYBACK   N  
clindamycin palmitate HCl CLEOCIN PEDIATRIC SOLN RECON   N  
clindamycin palmitate HCl CLINDAMYCIN (PEDIATRIC) SOLN RECON   N  
clindamycin phosphate CLINDAMYCIN PHOSPHATE VIAL   N  
clindamycin phosphate CLEOCIN PHOSPHATE VIAL   N  
clindamycin phosphate/D5W CLINDAMYCIN PHOSPHATE-D5W PGGYBK BTL   N  
clindamycin phosphate/D5W CLINDAMYCIN PHOSPHATE-D5W PIGGYBACK   N  
colistin (colistimethate Na) COLY-MYCIN M PARENTERAL VIAL   N  
colistin (colistimethate Na) COLISTIMETHATE VIAL   N  
dalbavancin HCl DALBAVANCIN HCL VIAL   N  
dalbavancin HCl DALVANCE VIAL   N  
daptomycin DAPTOMYCIN VIAL   N  
daptomycin in 0.9 % sod chlor DAPTOMYCIN-0.9% NACL FROZ.PIGGY   N  
delafloxacin meglumine BAXDELA VIAL   N  
ertapenem sodium ERTAPENEM VIAL   N  
imipenem/cilastatin sodium PRIMAXIN VIAL   N  
imipenem/cilastatin sodium IMIPENEM-CILASTATIN SODIUM VIAL   N  
imipenem/cilastatin/relebactam RECARBRIO VIAL   N  
lincomycin HCl LINCOMYCIN HCL VIAL   N  
lincomycin HCl LINCOCIN VIAL   N  
lincomycin HCl LINCOJECT VIAL   N  
linezolid in 0.9% sodium chlor LINEZOLID-0.9% NACL PIGGYBACK   N  
linezolid in dextrose 5% ZYVOX PIGGYBACK   N  
linezolid in dextrose 5% LINEZOLID-D5W PIGGYBACK   N  
meropenem MERREM INFUS. BTL   N  
meropenem MEROPENEM VIAL   N  
meropenem MERREM VIAL PORT   N  
meropenem-0.9% sodium chloride MEROPENEM-0.9% NACL PIGGYBACK   N  
meropenem/vaborbactam VABOMERE VIAL   N  
moxifloxacin-sod.chloride(iso) MOXIFLOXACIN PIGGYBACK   N  
moxifloxacin/sod.ace,sul/water MOXIFLOXACIN PIGGYBACK   N  
oritavancin diphosphate KIMYRSA VIAL   N  
oritavancin diphosphate ORBACTIV VIAL   N  
polymyxin B sulfate POLYMYXIN B SULFATE VIAL   N  
tedizolid phosphate SIVEXTRO VIAL   N  
telavancin HCl VIBATIV VIAL   N  
thalidomide THALOMID CAPSULE   N  
tigecycline TIGECYCLINE VIAL   N  
tigecycline TYGACIL VIAL   N  
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