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.
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 in dextrose 5 % LEVOFLOXACIN-D5W PIGGYBACK    
meth/meblue/sod phos/psal/hyos USTELL CAPSULE    
meth/meblue/sod phos/psal/hyos URO-MP CAPSULE    
meth/meblue/sod phos/psal/hyos URIMAR-T CAPSULE    
meth/meblue/sod phos/psal/hyos URIBEL CAPSULE    
meth/meblue/sod phos/psal/hyos PHOSPHASAL TABLET    
meth/meblue/sod phos/psal/hyos URELLE TABLET    
meth/meblue/sod phos/psal/hyos UTIRA-C TABLET    
methenam/m.blue/salicyl/hyoscy HYOPHEN TABLET    
methenam/m.blue/salicyl/hyoscy URIBEL TABS 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 URO-PAIN DUAL ACTION TABLET    
methenamine/sodium salicylate ANTIBACTERIAL-URINARY PAIN RLF TABLET    
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