Urinary Antibacterials, Analgesics
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 |
---|---|---|---|---|---|
levofloxacin in dextrose 5 % | LEVOFLOXACIN-D5W | PIGGYBACK | |||
meth/meblue/sod phos/psal/hyos | URO-MP | CAPSULE | |||
meth/meblue/sod phos/psal/hyos | URIBEL | CAPSULE | |||
meth/meblue/sod phos/psal/hyos | URIMAR-T | CAPSULE | |||
meth/meblue/sod phos/psal/hyos | USTELL | CAPSULE | |||
meth/meblue/sod phos/psal/hyos | URELLE | TABLET | |||
meth/meblue/sod phos/psal/hyos | UTIRA-C | TABLET | |||
meth/meblue/sod phos/psal/hyos | PHOSPHASAL | TABLET | |||
methenam/m.blue/salicyl/hyoscy | URIBEL TABS | TABLET | |||
methenam/m.blue/salicyl/hyoscy | HYOPHEN | TABLET | |||
methenam/sod phos/mblue/hyoscy | UROGESIC-BLUE | TABLET | |||
methenam/sod phos/mblue/hyoscy | ME-NAPHOS-MB-HYO 1 | TABLET | |||
methenamine hippurate | METHENAMINE HIPPURATE | TABLET | |||
methenamine mandelate | METHENAMINE MANDELATE | TABLET | |||
methenamine/sodium salicylate | ANTIBACTERIAL-URINARY PAIN RLF | TABLET | |||
methenamine/sodium salicylate | URO-PAIN DUAL ACTION | TABLET | |||
nitrofurantoin | NITROFURANTOIN | ORAL SUSP | |||
nitrofurantoin macrocrystal | NITROFURANTOIN | CAPSULE | |||
nitrofurantoin macrocrystal | NITROFURANTOIN MACROCRYSTAL | CAPSULE | |||
nitrofurantoin monohyd/m-cryst | MACROBID | CAPSULE | |||
nitrofurantoin monohyd/m-cryst | NITROFURANTOIN MONO-MACRO | CAPSULE |