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 | Carveout ‐ Bill FFS |
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 | PENTAMIDINE ISETHIONATE | VIAL-NEB | ||||
| pentamidine isethionate | NEBUPENT | VIAL-NEB | ||||
| praziquantel | PRAZIQUANTEL | TABLET | ||||
| pyrantel pamoate | PINWORM TREATMENT | ORAL SUSP | ||||
| triclabendazole | EGATEN | TABLET |