IV Solutions and Misc

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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.
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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
0.9 % sodium chloride SODIUM CHLORIDE AMPUL   N  
0.9 % sodium chloride SODIUM CHLORIDE PGGYBK PRT   N  
0.9 % sodium chloride SODIUM CHLORIDE VIAL   N  
AA 2.75 % no.2/D5W/lytes no.29 CLINIMIX E IV SOLN   N  
AA 4.25 % no.1/D5W/lytes no.39 CLINIMIX E IV SOLN   N  
AA 4.25 % no.1/dextrose 5 % CLINIMIX IV SOLN   N  
amino ac 8 %/D10W/electrolytes CLINIMIX E IV SOLN   N  
amino acid 6 % in 5 % dextrose CLINIMIX IV SOLN   N  
amino acid 8 % in D14W CLINIMIX IV SOLN   N  
amino acids 10 % TROPHAMINE IV SOLN   N  
amino acids 7 %/electrolytes AMINOSYN WITH ELECTROLYTES IV SOLN   N  
amino acids 8.5 %/electrolytes TRAVASOL WITH ELECTROLYTES IV SOLN   N  
amino acids 8.5 %/electrolytes TRAVASOL W/ELECTROLYTES IV SOLN   N  
calcium chloride CALCIUM CHLORIDE SYRINGE   N  
calcium gluc in NaCl, iso-osm CALCIUM GLUCONATE-NACL PLAST. BAG   N  
calcium gluconate CALCIUM GLUCONATE VIAL   N  
chromic chloride CHROMIUM VIAL   N  
copper gluconate COPPER TABLET   N  
cupric chloride CUPRIC CHLORIDE VIAL   N  
dex 2.5%-half str lact.ringers DEXTROSE IN LACTATED RINGERS IV SOLN   N  
dextrose 10 % and 0.2 % NaCl DEXTROSE 10%-0.2% NACL DEHP FR BG   N  
dextrose 10 % and 0.45 % NaCl DEXTROSE 10%-0.45% NACL IV SOLN   N  
dextrose 10 % in water DEXTROSE IN WATER DEHP FR BG   N  
dextrose 2.5 % and 0.45 % NaCl DEXTROSE 2.5%-0.45% NACL IV SOLN   N  
dextrose 2.5 % and 0.45 % NaCl DEXTROSE WITH SODIUM CHLORIDE IV SOLN   N  
dextrose 2.5 % in water DEXTROSE IN WATER IV SOLN   N  
dextrose 2.5% in half ringers DEXTROSE IN RINGERS INJECTION IV SOLN   N  
dextrose 20 % in water DEXTROSE IN WATER IV SOLN   N  
dextrose 30 % in water DEXTROSE IN WATER IV SOLN   N  
dextrose 5 % and 0.3 % NaCl DEXTROSE 5%-0.33% NACL IV SOLN   N  
dextrose 5 % and 0.9 % NaCl DEXTROSE 5%-0.9% NACL IV SOLN   N  
dextrose 5 % in Ringer's DEXTROSE IN RINGERS INJECTION IV SOLN   N  
dextrose 5 % in water GLUCOSE IN WATER IV SOLN   N  
dextrose 5 % in water DEXTROSE IN WATER PGGYBK PRT   N  
dextrose 5 % in water DEXTROSE IN WATER VIAL   N  
dextrose 5 %-0.2 % sod chlorid DEXTROSE 5%-0.2% NACL IV SOLN   N  
dextrose 5 %-0.2 % sod chlorid DEXTROSE WITH SODIUM CHLORIDE IV SOLN   N  
dextrose 5%-lactated ringers DEXTROSE IN LACTATED RINGERS IV SOLN   N  
dextrose 50 % in water GLUCOSE IN WATER IV SOLN   N  
dextrose 50 % in water DEXTROSE IN WATER SYRINGE   N  
dextrose 70 % in water GLUCOSE IN WATER IV SOLN   N  
electrolyte solution,inj HYPERLYTE R VIAL   N  
electrolyte solution,inj HYPERLYTE VIAL   N  
electrolyte-148 (pH 7.4) PLASMA-LYTE 148 PH 7.4 IV SOLN   N  
Electrolyte-2/Invert Sugar 5% TRAVERT-ELECTROLYTE NO.2 IV SOLN   N  
electrolyte-48 solution/D5W DEXTROSE 5%-ELECTROLYTE #48 IV SOLN   N  
Electrolyte-48/fructose 5 % FRUCTOSE-ELECTROLYTE NO.48 IV SOLN   N  
Electrolyte-75/fructose 5 % FRUCTOSE-ELECTROLYTE NO.75 IV SOLN   N  
electrolyte-B solution/D50W DEXTROSE W/ELECTROLYTE B IV SOLN   N  
electrolyte-P solution/D5W ISOLYTE P WITH DEXTROSE IV SOLN   N  
electrolyte-R solution NORMOSOL-R IV SOLN   N  
electrolyte-S in 5 % dextrose ISOLYTE S WITH DEXTROSE IV SOLN   N  
electrolytes/dextrose HYDRATING ELECTROLYTE PACKET   N  
electrolytes/dextrose PEDIALYTE SOLUTION   N  
electrolytes/dextrose PEDIATRIC ELECTROLYTE SOLUTION   N  
electrolytes/dextrose WELL LYTE ADVANCED HYDRATION SOLUTION   N  
fructose 10 % FRUCTOSE IV SOLN   N  
intraventricular electrolytes1 INTRAVENTRICULAR ELECTROLYTES VIAL   N  
inverted sugar 10% in 0.9%NaCl TRAVERT IN NORMAL SALINE IV SOLN   N  
KCl in inverted sugar 10%-NaCl TRAVERT-1/2 NS WITH KCL IV SOLN   N  
Lytes/inverted sugar 10 % TRAVERT-ELECTROLYTE NO.2 IV SOLN   N  
magnesium carbonate/sod bicarb RENACARB TABLET DR   N  
magnesium sulfate MAGNESIUM SULFATE SYRINGE   N  
magnesium sulfate in water MAGNESIUM SULFATE IV SOLN   N  
magnesium sulfate/D5W MAGNESIUM SULFATE-D5W INFUS. BTL   N  
manganese chloride MANGANESE VIAL   N  
nutritional supplement REABILAN LIQUID Pharmacy PA N  
nutritional supplement NUBASICS POWDER Pharmacy PA N  
parent amino ac 5.2 % (renal) AMINOSYN-RF IV SOLN   N  
parent.amino acid 10% no5(ped) AMINOSYN-PF IV SOLN   N  
parenteral amino acid 10% no.6 TRAVASOL IV SOLN   N  
parenteral amino acid 15% no.1 NOVAMINE IV SOLN   N  
parenteral amino acid 15% no.5 CLINISOL IV SOLN   N  
parenteral amino acid 15% no.6 PLENAMINE IV SOLN   N  
parenteral amino acid 20% no.1 PROSOL IV SOLN   N  
parenteral amino acid 7 % no.2 AMINOSYN II IV SOLN   N  
perit. dialysis 19-dextr 1.5 % DELFLEX WITH 1.5% DEXTROSE IP SOLN   N  
perit. dialysis 3-dextr 4.25 % DIALYTE LM W/DEXTROSE 4.25% IP SOLN   N  
perit. dialysis 3-dextr 4.25 % DIANEAL PD-2 W-4.25% DEXTROSE IP SOLN   N  
perit. dialysis no.6-dex 1.5 % DIANEAL WITH 1.5% DEXTROSE IP SOLN   N  
periton. dialysis 13-dex 2.5 % DIANEAL PD-2 W-2.5% DEXTROSE IP SOLN   N  
periton. dialysis 4-dext 1.5 % DIALYTE LM W/DEXTROSE 1.5% IP SOLN   N  
periton.dialysis 7-dextr 2.5 % DELFLEX WITH 2.5% DEXTROSE IP SOLN   N  
periton.dialysis 7-dextr 2.5 % DIANEAL PD-4 WITH 2.5% DEXTROS IP SOLN   N  
periton.dialysis 8-dext 4.25 % DIANEAL PD4 WITH 3.86% GLUCOSE IP SOLN   N  
potassium acetate POTASSIUM ACETATE VIAL   N  
potassium chloride POTASSIUM CHLORIDE VIAL   N  
potassium chloride in 0.9%NaCl POTASSIUM CHLORIDE-0.9% NACL IV SOLN   N  
potassium chloride in D5W POTASSIUM CHLORIDE-DEXTROSE 5% IV SOLN   N  
potassium chloride in water POTASSIUM CHLORIDE PIGGYBACK   N  
potassium chloride/D5-0.2%NaCl KCL-D5W-0.2% NACL IV SOLN   N  
potassium chloride/D5-0.2%NaCl KCL-D5W-0.225% NACL IV SOLN   N  
potassium chloride/D5-0.3%NaCl KCL-D5W-0.3% NACL IV SOLN   N  
potassium chloride/D5-0.3%NaCl DEXTROSE 5%-1/3NS-KCL IV SOLN   N  
potassium chloride/D5-0.45NaCl DEXTROSE 5%-1/2NS-KCL IV SOLN   N  
potassium chloride/D5-0.9%NaCl KCL-D5W-0.9% NACL IV SOLN   N  
potassium phos in 0.9 % NaCl POTASSIUM PHOSPHATE-0.9% NACL PIGGYBACK   N  
potassium phos,m-basic-d-basic POTASSIUM PHOSPHATE VIAL   N  
Ringer's solution RINGERS INJECTION IV SOLN   N  
selenium SELENIOUS ACID VIAL   N  
sodium acetate SODIUM ACETATE VIAL   N  
sodium bicarbonate SODIUM BICARBONATE IV SOLN   N  
sodium chloride SODIUM CHLORIDE SOLUTION   N  
sodium chloride SODIUM CHLORIDE VIAL   N  
sodium chloride 0.45 % SODIUM CHLORIDE IV SOLN   N  
sodium chloride 0.9 % (flush) SODIUM CHLORIDE SYRINGE   N  
sodium chloride 5 % SODIUM CHLORIDE IV SOLN   N  
triheptanoin DOJOLVI LIQUID Pharmacy PA N  
tromethamine TROMETHAMINE IV SOLN   N  
zinc amino acid chelate ZINC CHELATED TABLET   N  
zinc sulfate VERAZINC CAPSULE   N  
zinc/copper/manganese/selenium MULTRYS VIAL   N  
Zn/Cu/mang/selen/fluor/pot iod PEDITRACE VIAL   N  
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