Protein Lysates
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 |
|---|---|---|---|---|---|
| AA 5.5 %/electrolyte-TPN soln | TRAVASOL WITH ELECTROLYTES | IV SOLN | |||
| AA 5.5 %/electrolyte-TPN soln | TRAVASOL W/ELECTROLYTES | IV SOLN | |||
| amino acids | AMINO ACID MEGA | TABLET | PA Document | ||
| amino acids 5.5 % | TRAVASOL | IV SOLN | |||
| amino acids 5.5 %/dextrose 10% | TRAVASOL W/DEXTROSE | IV SOLN | |||
| amino acids 7 %/dextrose 50 % | AMINOSYN | KIT | |||
| arginine | ARGININE | TABLET | PA Document | ||
| cysteine HCl | L-CYSTEINE | SYRINGE | |||
| cysteine HCl | ELCYS | VIAL | |||
| cysteine HCl | CYSTEINE HYDROCHLORIDE | VIAL | |||
| lysine | LYSINE | TABLET | PA Document |