Antiparasitics
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 & Updates |
|---|---|---|---|---|---|
| albendazole | ALBENDAZOLE | TABLET | |||
| atovaquone | ATOVAQUONE | ORAL SUSP | |||
| atovaquone | MEPRON | ORAL SUSP | |||
| benznidazole | BENZNIDAZOLE | TABLET | |||
| dapsone | DAPSONE | TABLET | |||
| ivermectin | IVERMECTIN | TABLET | |||
| ivermectin | STROMECTOL | TABLET | |||
| mebendazole | EMVERM | TAB CHEW | |||
| metronidazole/sodium chloride | METRONIDAZOLE | PIGGYBACK | |||
| metronidazole/sodium chloride | METRO IV | PIGGYBACK | |||
| nifurtimox | LAMPIT | TABLET | |||
| nitazoxanide | NITAZOXANIDE | TABLET | |||
| paromomycin sulfate | PAROMOMYCIN SULFATE | CAPSULE | |||
| pentamidine isethionate | PENTAMIDINE ISETHIONATE | VIAL | |||
| pentamidine isethionate | PENTAM 300 | VIAL | |||
| pentamidine isethionate | NEBUPENT | VIAL-NEB | |||
| pentamidine isethionate | PENTAMIDINE ISETHIONATE | VIAL-NEB | |||
| praziquantel | PRAZIQUANTEL | TABLET | |||
| praziquantel | BILTRICIDE | TABLET | |||
| triclabendazole | EGATEN | TABLET |