Antimalarials
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 |
---|---|---|---|---|---|
artemether/lumefantrine | COARTEM | TABLET | |||
artesunate | ARTESUNATE | VIAL | |||
atovaquone/proguanil HCl | ATOVAQUONE-PROGUANIL HCL | TABLET | |||
atovaquone/proguanil HCl | MALARONE | TABLET | |||
chloroquine phosphate | CHLOROQUINE PHOSPHATE | TABLET | |||
halofantrine HCl | HALFAN | TABLET | |||
hydroxychloroquine sulfate | HYDROXYCHLOROQUINE SULFATE | TABLET | |||
hydroxychloroquine sulfate | SOVUNA | TABLET | |||
mefloquine HCl | MEFLOQUINE HCL | TABLET | |||
primaquine phosphate | PRIMAQUINE | TABLET | |||
pyrimethamine | PYRIMETHAMINE | TABLET | |||
quinine sulfate | QUININE SULFATE | CAPSULE | |||
quinine sulfate | QUALAQUIN | CAPSULE | |||
quinine sulfate | QUININE SULFATE | TABLET | |||
tafenoquine succinate | KRINTAFEL | TABLET |