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.

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Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria Carveout
‐ Bill FFS
New Drug Evaluation & Updates
meth/meblue/sod phos/psal/hyos USTELL CAPSULE   N  
meth/meblue/sod phos/psal/hyos URIMAR-T CAPSULE   N  
meth/meblue/sod phos/psal/hyos URELLE TABLET   N  
methenam/m.blue/salicyl/hyoscy HYOPHEN TABLET   N  
methenam/m.blue/salicyl/hyoscy URIBEL TABS TABLET   N  
methenam/sod phos/mblue/hyoscy UROGESIC-BLUE TABLET   N  
methenamine hippurate METHENAMINE HIPPURATE TABLET   N  
methenamine mandelate METHENAMINE MANDELATE TABLET   N  
methenamine/sodium salicylate ANTIBACTERIAL-URINARY PAIN RLF TABLET   N  
nitrofurantoin NITROFURANTOIN ORAL SUSP   N  
nitrofurantoin monohyd/m-cryst MACROBID CAPSULE   N