Cephalosporins (2nd 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
61442017130 CEFACLOR cefaclor CAPSULE 250 mg N Y N  
61442017230 CEFACLOR cefaclor CAPSULE 500 mg N Y N  
00378760212 CEFACLOR cefaclor SUSP RECON 125 mg/5 mL N Y N  
23594012501 CEFACLOR cefaclor SUSP RECON 125 mg/5 mL N Y N  
23594037501 CEFACLOR cefaclor SUSP RECON 375 mg/5 mL N Y N  
00093108701 CEFACLOR ER cefaclor TAB ER 12H 500 mg N Y N  
16714039602 CEFPROZIL cefprozil SUSP RECON 125 mg/5 mL Y Y N  
16714039603 CEFPROZIL cefprozil SUSP RECON 125 mg/5 mL Y Y N  
57237003401 CEFPROZIL cefprozil SUSP RECON 125 mg/5 mL Y Y N  
57237003450 CEFPROZIL cefprozil SUSP RECON 125 mg/5 mL Y Y N  
57237003475 CEFPROZIL cefprozil SUSP RECON 125 mg/5 mL Y Y N  
68180040103 CEFPROZIL cefprozil SUSP RECON 125 mg/5 mL Y Y N  
16714039701 CEFPROZIL cefprozil SUSP RECON 250 mg/5 mL Y Y N  
16714039702 CEFPROZIL cefprozil SUSP RECON 250 mg/5 mL Y Y N  
16714039703 CEFPROZIL cefprozil SUSP RECON 250 mg/5 mL Y Y N  
57237003501 CEFPROZIL cefprozil SUSP RECON 250 mg/5 mL Y Y N  
57237003550 CEFPROZIL cefprozil SUSP RECON 250 mg/5 mL Y Y N  
57237003575 CEFPROZIL cefprozil SUSP RECON 250 mg/5 mL Y Y N  
68180040201 CEFPROZIL cefprozil SUSP RECON 250 mg/5 mL Y Y N  
68180040202 CEFPROZIL cefprozil SUSP RECON 250 mg/5 mL Y Y N  
68180040203 CEFPROZIL cefprozil SUSP RECON 250 mg/5 mL Y Y N  
00093107701 CEFPROZIL cefprozil TABLET 250 mg Y Y N  
16714039801 CEFPROZIL cefprozil TABLET 250 mg Y Y N  
57237003601 CEFPROZIL cefprozil TABLET 250 mg Y Y N  
67877024401 CEFPROZIL cefprozil TABLET 250 mg Y Y N  
68180040301 CEFPROZIL cefprozil TABLET 250 mg Y Y N  
00093107853 CEFPROZIL cefprozil TABLET 500 mg Y Y N  
16714039901 CEFPROZIL cefprozil TABLET 500 mg Y Y N  
57237003750 CEFPROZIL cefprozil TABLET 500 mg Y Y N  
65862006901 CEFPROZIL cefprozil TABLET 500 mg Y Y N  
67877024350 CEFPROZIL cefprozil TABLET 500 mg Y Y N  
68180040401 CEFPROZIL cefprozil TABLET 500 mg Y Y N  
00904754210 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
16714040001 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
16714040002 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
57237005820 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
57237005860 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
60687027211 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
60687027294 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
65862003460 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
65862069920 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
65862069960 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
67877021520 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
67877021560 CEFUROXIME cefuroxime axetil TABLET 250 mg Y Y N  
16714040101 CEFUROXIME cefuroxime axetil TABLET 500 mg Y Y N  
16714040102 CEFUROXIME cefuroxime axetil TABLET 500 mg Y Y N  
57237005920 CEFUROXIME cefuroxime axetil TABLET 500 mg Y Y N  
57237005960 CEFUROXIME cefuroxime axetil TABLET 500 mg Y Y N  
60687028311 CEFUROXIME cefuroxime axetil TABLET 500 mg Y Y N  
60687028394 CEFUROXIME cefuroxime axetil TABLET 500 mg Y Y N  
65862070020 CEFUROXIME cefuroxime axetil TABLET 500 mg Y Y N  
65862070060 CEFUROXIME cefuroxime axetil TABLET 500 mg Y Y N  
67877021620 CEFUROXIME cefuroxime axetil TABLET 500 mg Y Y N  
67877021660 CEFUROXIME cefuroxime axetil TABLET 500 mg Y Y N  
00002317030 LORABID loracarbef CAPSULE 200 mg N Y N  
00002513587 LORABID loracarbef SUSP RECON 100 mg/5 mL N Y N  
00002513618 LORABID loracarbef SUSP RECON 200 mg/5 mL N Y N  
00002513687 LORABID loracarbef SUSP RECON 200 mg/5 mL N Y N  
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