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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| aminophylline | AMINOPHYLLINE | VIAL | N | |||
| caffeine | CAFFEINE | TABLET | N | |||
| caffeine | STAY AWAKE | TABLET | N | |||
| caffeine citrate | CAFFEINE CITRATE | SOLUTION | N | |||
| caffeine/sodium benzoate | CAFFEINE AND SODIUM BENZOATE | VIAL | N | |||
| oxtriphylline | CHOLEDYL SA | TABLET ER | N | |||
| theophylline anhydrous | THEO-24 | CAP ER 24H | N | |||
| theophylline anhydrous | THEOPHYLLINE ER | TAB ER 12H | N | |||
| theophylline anhydrous | THEOPHYLLINE ER | TAB ER 24H | N |