Cephalosporins (1st Gen), Oral

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PDL Reference Documents

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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00093319601 CEFADROXIL cefadroxil CAPSULE 500 mg N Y N  
00093319653 CEFADROXIL cefadroxil CAPSULE 500 mg N Y N  
16714038801 CEFADROXIL cefadroxil CAPSULE 500 mg N Y N  
16714038802 CEFADROXIL cefadroxil CAPSULE 500 mg N Y N  
57237009601 CEFADROXIL cefadroxil CAPSULE 500 mg N Y N  
57237009650 CEFADROXIL cefadroxil CAPSULE 500 mg N Y N  
65862008501 CEFADROXIL cefadroxil CAPSULE 500 mg N Y N  
65862008550 CEFADROXIL cefadroxil CAPSULE 500 mg N Y N  
68180018001 CEFADROXIL cefadroxil CAPSULE 500 mg N Y N  
68180018008 CEFADROXIL cefadroxil CAPSULE 500 mg N Y N  
16714038901 CEFADROXIL cefadroxil SUSP RECON 250 mg/5 mL N Y N  
57237009701 CEFADROXIL cefadroxil SUSP RECON 250 mg/5 mL N Y N  
65862008301 CEFADROXIL cefadroxil SUSP RECON 250 mg/5 mL N Y N  
68180018102 CEFADROXIL cefadroxil SUSP RECON 250 mg/5 mL N Y N  
16714039001 CEFADROXIL cefadroxil SUSP RECON 500 mg/5 mL N Y N  
16714039002 CEFADROXIL cefadroxil SUSP RECON 500 mg/5 mL N Y N  
57237009801 CEFADROXIL cefadroxil SUSP RECON 500 mg/5 mL N Y N  
57237009875 CEFADROXIL cefadroxil SUSP RECON 500 mg/5 mL N Y N  
65862008401 CEFADROXIL cefadroxil SUSP RECON 500 mg/5 mL N Y N  
65862008475 CEFADROXIL cefadroxil SUSP RECON 500 mg/5 mL N Y N  
68180018202 CEFADROXIL cefadroxil SUSP RECON 500 mg/5 mL N Y N  
68180018203 CEFADROXIL cefadroxil SUSP RECON 500 mg/5 mL N Y N  
00093405953 CEFADROXIL cefadroxil TABLET 1 gram N Y N  
00093314501 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
00093314505 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
00904733661 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
50268015111 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
50268015115 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
60687015201 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
60687015211 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
62135071074 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
65862001801 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
65862001805 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
65862001840 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
67877022001 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
67877022005 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
68180012101 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
68180012102 CEPHALEXIN cephalexin CAPSULE 250 mg Y Y N  
00093314701 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
00093314705 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
00904733706 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
00904733735 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
00904733761 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
50268015211 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
50268015215 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
60687016301 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
60687016311 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
62135071174 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
65862001901 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
65862001905 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
65862001940 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
67877021901 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
67877021905 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
68180012201 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
68180012202 CEPHALEXIN cephalexin CAPSULE 500 mg Y Y N  
59651072820 CEPHALEXIN cephalexin CAPSULE 750 mg N Y N  
59651072850 CEPHALEXIN cephalexin CAPSULE 750 mg N Y N  
67877025520 CEPHALEXIN cephalexin CAPSULE 750 mg N Y N  
67877025523 CEPHALEXIN cephalexin CAPSULE 750 mg N Y N  
00093417573 CEPHALEXIN cephalexin SUSP RECON 125 mg/5 mL Y Y N  
00093417574 CEPHALEXIN cephalexin SUSP RECON 125 mg/5 mL Y Y N  
62135048042 CEPHALEXIN cephalexin SUSP RECON 125 mg/5 mL Y Y N  
62135048049 CEPHALEXIN cephalexin SUSP RECON 125 mg/5 mL Y Y N  
67877054468 CEPHALEXIN cephalexin SUSP RECON 125 mg/5 mL Y Y N  
67877054488 CEPHALEXIN cephalexin SUSP RECON 125 mg/5 mL Y Y N  
68180044001 CEPHALEXIN cephalexin SUSP RECON 125 mg/5 mL Y Y N  
68180044002 CEPHALEXIN cephalexin SUSP RECON 125 mg/5 mL Y Y N  
00093417773 CEPHALEXIN cephalexin SUSP RECON 250 mg/5 mL Y Y N  
00093417774 CEPHALEXIN cephalexin SUSP RECON 250 mg/5 mL Y Y N  
62135048142 CEPHALEXIN cephalexin SUSP RECON 250 mg/5 mL Y Y N  
62135048149 CEPHALEXIN cephalexin SUSP RECON 250 mg/5 mL Y Y N  
67877054568 CEPHALEXIN cephalexin SUSP RECON 250 mg/5 mL Y Y N  
67877054588 CEPHALEXIN cephalexin SUSP RECON 250 mg/5 mL Y Y N  
68180044101 CEPHALEXIN cephalexin SUSP RECON 250 mg/5 mL Y Y N  
68180044102 CEPHALEXIN cephalexin SUSP RECON 250 mg/5 mL Y Y N  
00093223801 CEPHALEXIN cephalexin TABLET 250 mg N Y N  
59651078301 CEPHALEXIN cephalexin TABLET 250 mg N Y N  
67877089101 CEPHALEXIN cephalexin TABLET 250 mg N Y N  
00093224001 CEPHALEXIN cephalexin TABLET 500 mg N Y N  
59651078401 CEPHALEXIN cephalexin TABLET 500 mg N Y N  
67877089201 CEPHALEXIN cephalexin TABLET 500 mg N Y N  
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