Urinary Antibacterials, Analgesics

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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
Current Drug Use Criteria New Drug Evaluation
levofloxacin LEVOFLOXACIN VIAL    
levofloxacin in dextrose 5 % LEVOFLOXACIN-D5W PIGGYBACK    
meth/meblue/sod phos/psal/hyos URIBEL CAPSULE    
meth/meblue/sod phos/psal/hyos URO-MP CAPSULE    
meth/meblue/sod phos/psal/hyos URAMIT MB CAPSULE    
meth/meblue/sod phos/psal/hyos UTIRA-C TABLET    
meth/meblue/sod phos/psal/hyos URO-L TABLET    
meth/meblue/sod phos/psal/hyos URIN D.S. TABLET    
meth/meblue/sod phos/psal/hyos URELLE TABLET    
meth/meblue/sod phos/psal/hyos HYOLEV MB TABLET    
meth/meblue/sod phos/psal/hyos URO-458 TABLET    
methen/mblue/sal/sod phos/hyos USTELL CAPSULE    
methen/mblue/sal/sod phos/hyos AZUPHEN MB CAPSULE    
methen/mblue/sal/sod phos/hyos URIMAR-T TABLET    
methenam/m.blue/salicyl/hyoscy UROPHEN MB TABLET    
methenam/sod phos/mblue/hyoscy INDIOMIN MB CAPSULE    
methenam/sod phos/mblue/hyoscy ME-NAPHOS-MB-HYO 1 TABLET    
methenam/sod phos/mblue/hyoscy URO-BLUE TABLET    
methenam/sod phos/mblue/hyoscy UROGESIC-BLUE TABLET    
methenamine hippurate METHENAMINE HIPPURATE TABLET    
methenamine hippurate HIPREX TABLET    
methenamine mandelate METHENAMINE MANDELATE TABLET    
nitrofurantoin FURADANTIN ORAL SUSP    
nitrofurantoin macrocrystal NITROFURANTOIN MACROCRYSTAL CAPSULE    
nitrofurantoin macrocrystal NITROFURANTOIN CAPSULE    
nitrofurantoin macrocrystal MACRODANTIN CAPSULE    
nitrofurantoin monohyd/m-cryst MACROBID CAPSULE    
nitrofurantoin monohyd/m-cryst NITROFURANTOIN MONO-MACRO CAPSULE