Amoxicillin and Clavulanate, 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
28595024035 AUGMENTIN amoxicillin/potassium clav SUSP RECON 125 mg-31.25 mg/5 mL Y Y N  
28595024036 AUGMENTIN amoxicillin/potassium clav SUSP RECON 125 mg-31.25 mg/5 mL Y Y N  
00093227773 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
00143998101 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
00143998150 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
00143998175 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
00781610246 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
00781610252 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
00781610257 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
16714029201 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
16714029202 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
16714029203 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
42571016347 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
65862053301 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
65862053350 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
65862053375 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
69452033443 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 200 mg-28.5 mg/5 mL Y Y N  
59651002601 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
59651002655 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
59651002675 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
69097009808 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
69097009843 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
69097009844 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
73043001001 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
73043001002 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
73043001003 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
81964020407 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
81964020410 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
81964020415 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 250 mg-62.5 mg/5 mL Y Y N  
00093227973 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
00143998201 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
00143998250 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
00143998275 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
00781610446 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
00781610452 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
00781610457 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
16714029301 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
16714029302 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
16714029303 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
42571016447 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
65862053401 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
65862053450 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
65862053475 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
69452033543 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
73043000901 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
73043000902 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
73043000903 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 400 mg-57 mg/5 mL Y Y N  
00093867574 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
00093867575 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
00093867578 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
00143985316 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
00143985324 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
00143985375 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
00781613948 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
00781613954 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
00781613957 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
16714029401 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
16714029402 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
16714029403 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
65862053502 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
65862053513 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
65862053575 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
73043000801 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
73043000802 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
73043000803 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
81964020351 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
81964020354 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
81964020369 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
81964000351 AUGMENTIN ES-600 amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
81964000354 AUGMENTIN ES-600 amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
81964000369 AUGMENTIN ES-600 amoxicillin/potassium clav SUSP RECON 600 mg-42.9 mg/5 mL Y Y N  
00093227034 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TAB CHEW 200 mg-28.5 mg Y Y N  
00093227234 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TAB CHEW 400 mg-57 mg Y Y N  
00781194339 AMOXICILLIN-CLAVULANATE POT ER amoxicillin/potassium clav TAB ER 12H 1,000 mg-62.5 mg N Y N  
00781194382 AMOXICILLIN-CLAVULANATE POT ER amoxicillin/potassium clav TAB ER 12H 1,000 mg-62.5 mg N Y N  
00781187431 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 250 mg-125 mg Y Y N  
16714029501 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 250 mg-125 mg Y Y N  
16714047601 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 250 mg-125 mg Y Y N  
42571016030 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 250 mg-125 mg Y Y N  
60687078111 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 250 mg-125 mg Y Y N  
60687078194 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 250 mg-125 mg Y Y N  
65862050130 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 250 mg-125 mg Y Y N  
00093227434 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 500 mg-125 mg Y Y N  
00781183101 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 500 mg-125 mg Y Y N  
00781183120 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 500 mg-125 mg Y Y N  
16714029601 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 500 mg-125 mg Y Y N  
42571016101 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 500 mg-125 mg Y Y N  
42571016142 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 500 mg-125 mg Y Y N  
60687079201 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 500 mg-125 mg Y Y N  
60687079211 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 500 mg-125 mg Y Y N  
62135046220 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 500 mg-125 mg Y Y N  
65862050220 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 500 mg-125 mg Y Y N  
69452033611 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 500 mg-125 mg Y Y N  
00093227534 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
00143924920 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
00781185201 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
00781185220 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
16714001402 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
16714029701 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
16714029702 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
42571016201 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
42571016242 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
60687080301 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
60687080311 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
62135046320 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
65862050301 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
65862050320 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
66685100100 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
69452033711 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
81964022101 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
81964022114 AMOXICILLIN-CLAVULANATE POTASS amoxicillin/potassium clav TABLET 875 mg-125 mg Y Y N  
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