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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 but eligible patients will encounter a co-pay at the pharmacy.
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
permethrin LICE BEDDING SPRAY N    
albendazole ALBENZA TABLET    
albendazole ALBENDAZOLE TABLET    
atovaquone MEPRON ORAL SUSP    
benznidazole BENZNIDAZOLE TABLET    
dapsone DAPSONE TABLET    
ivermectin IVERMECTIN TABLET    
ivermectin STROMECTOL TABLET    
mebendazole EMVERM TAB CHEW    
metronidazole/sodium chloride METRO IV PIGGYBACK    
metronidazole/sodium chloride METRONIDAZOLE PIGGYBACK    
nitazoxanide ALINIA SUSP RECON    
paromomycin sulfate PAROMOMYCIN SULFATE CAPSULE    
pentamidine isethionate PENTAM 300 VIAL    
pentamidine isethionate PENTAMIDINE ISETHIONATE VIAL    
pentamidine isethionate NEBUPENT VIAL-NEB    
praziquantel PRAZIQUANTEL TABLET    
praziquantel BILTRICIDE TABLET    
triclabendazole EGATEN TABLET