Xanthine Derivatives
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 |
---|---|---|---|---|---|
aminophylline | AMINOPHYLLINE | SYRINGE | |||
aminophylline | AMINOPHYLLINE | VIAL | |||
caffeine | ALERT AID | TABLET | |||
caffeine | CAFFEINE | TABLET | |||
caffeine | STAY AWAKE | TABLET | |||
caffeine citrate | CAFFEINE CITRATE | SOLUTION | |||
caffeine citrate | CAFCIT | VIAL | |||
caffeine citrate | CAFFEINE CITRATE | VIAL | |||
caffeine/sodium benzoate | CAFFEINE AND SODIUM BENZOATE | VIAL | |||
dyphylline | LUFYLLIN-400 | TABLET | |||
dyphylline | DILOR | TABLET | |||
oxtriphylline | CHOLEDYL SA | TABLET ER | |||
theophylline anhydrous | THEO-24 | CAP ER 24H | |||
theophylline anhydrous | THEOPHYLLINE | ELIXIR | |||
theophylline anhydrous | THEOPHYLLINE | SOLUTION | |||
theophylline anhydrous | THEOPHYLLINE ER | TAB ER 12H | |||
theophylline anhydrous | QUIBRON-T/SR | TAB ER 12H | |||
theophylline anhydrous | THEOPHYLLINE ER | TAB ER 24H | |||
theophylline in dextrose 5 % | THEOPHYLLINE IN 5% DEXTROSE | IV SOLN |