Fluoroquinolones, Oral

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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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
50419077701 CIPRO ciprofloxacin SUS MC REC 250 mg/5 mL Y Y N  
62135039242 CIPROFLOXACIN ciprofloxacin SUS MC REC 250 mg/5 mL Y Y N  
50419077301 CIPRO ciprofloxacin SUS MC REC 500 mg/5 mL Y Y N  
62135039342 CIPROFLOXACIN ciprofloxacin SUS MC REC 500 mg/5 mL Y Y N  
50419075801 CIPRO ciprofloxacin HCl TABLET 250 mg Y Y N  
00143992701 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 250 mg Y Y N  
16252051401 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 250 mg Y Y N  
16571041110 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 250 mg Y Y N  
43547068810 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 250 mg Y Y N  
59651086601 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 250 mg Y Y N  
60687052811 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 250 mg Y Y N  
61442022201 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 250 mg Y Y N  
62135030801 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 250 mg Y Y N  
65862007601 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 250 mg Y Y N  
69367038501 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 250 mg Y Y N  
50419075401 CIPRO ciprofloxacin HCl TABLET 500 mg Y Y N  
00143992801 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
00904708395 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
00904724361 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
00904724395 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
13107007701 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
16252051501 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
16571041210 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
16571041250 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
43547068910 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
43547068950 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
59651086701 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
59651086705 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
60687086001 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
60687086011 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
61442022301 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
61442022305 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
62135030901 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
62135030905 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
62135030920 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
62135030928 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
65862007701 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
65862007705 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
69367038601 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
69367038605 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 500 mg Y Y N  
00085175601 CIPRO ciprofloxacin HCl TABLET 750 mg Y Y N  
00085175602 CIPRO ciprofloxacin HCl TABLET 750 mg Y Y N  
00143992950 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 750 mg Y Y N  
16252051605 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 750 mg Y Y N  
16571041305 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 750 mg Y Y N  
59651087350 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 750 mg Y Y N  
61442022450 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 750 mg Y Y N  
62135031050 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 750 mg Y Y N  
65862007850 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 750 mg Y Y N  
69367038750 CIPROFLOXACIN HCL ciprofloxacin HCl TABLET 750 mg Y Y N  
50419078901 CIPRO XR ciprofloxacin/ciprofloxa HCl TBMP 24HR 1,000 mg N Y N  
50419078801 CIPRO XR ciprofloxacin/ciprofloxa HCl TBMP 24HR 500 mg N Y N  
70842010101 BAXDELA delafloxacin meglumine TABLET 450 mg N Y N  
70842010102 BAXDELA delafloxacin meglumine TABLET 450 mg N Y N  
70842010103 BAXDELA delafloxacin meglumine TABLET 450 mg N Y N  
00527194866 LEVOFLOXACIN levofloxacin SOLUTION 250 mg/10 mL Y Y N  
00527194868 LEVOFLOXACIN levofloxacin SOLUTION 250 mg/10 mL Y Y N  
00527194870 LEVOFLOXACIN levofloxacin SOLUTION 250 mg/10 mL Y Y N  
70954085210 LEVOFLOXACIN levofloxacin SOLUTION 250 mg/10 mL Y Y N  
70954085220 LEVOFLOXACIN levofloxacin SOLUTION 250 mg/10 mL Y Y N  
70954085230 LEVOFLOXACIN levofloxacin SOLUTION 250 mg/10 mL Y Y N  
00904635161 LEVOFLOXACIN levofloxacin TABLET 250 mg Y Y N  
31722072150 LEVOFLOXACIN levofloxacin TABLET 250 mg Y Y N  
33342053108 LEVOFLOXACIN levofloxacin TABLET 250 mg Y Y N  
55111027950 LEVOFLOXACIN levofloxacin TABLET 250 mg Y Y N  
62135065514 LEVOFLOXACIN levofloxacin TABLET 250 mg Y Y N  
65862053650 LEVOFLOXACIN levofloxacin TABLET 250 mg Y Y N  
72578009818 LEVOFLOXACIN levofloxacin TABLET 250 mg Y Y N  
00904635261 LEVOFLOXACIN levofloxacin TABLET 500 mg Y Y N  
31722072250 LEVOFLOXACIN levofloxacin TABLET 500 mg Y Y N  
33342053208 LEVOFLOXACIN levofloxacin TABLET 500 mg Y Y N  
55111028050 LEVOFLOXACIN levofloxacin TABLET 500 mg Y Y N  
62135065650 LEVOFLOXACIN levofloxacin TABLET 500 mg Y Y N  
65862053750 LEVOFLOXACIN levofloxacin TABLET 500 mg Y Y N  
72578009918 LEVOFLOXACIN levofloxacin TABLET 500 mg Y Y N  
00904635361 LEVOFLOXACIN levofloxacin TABLET 750 mg Y Y N  
31722072320 LEVOFLOXACIN levofloxacin TABLET 750 mg Y Y N  
33342002332 LEVOFLOXACIN levofloxacin TABLET 750 mg Y Y N  
33342053332 LEVOFLOXACIN levofloxacin TABLET 750 mg Y Y N  
55111028130 LEVOFLOXACIN levofloxacin TABLET 750 mg Y Y N  
62135065714 LEVOFLOXACIN levofloxacin TABLET 750 mg Y Y N  
65862053820 LEVOFLOXACIN levofloxacin TABLET 750 mg Y Y N  
72578010006 LEVOFLOXACIN levofloxacin TABLET 750 mg Y Y N  
72578010092 LEVOFLOXACIN levofloxacin TABLET 750 mg Y Y N  
00051165132 MAXAQUIN lomefloxacin HCl TABLET 400 mg N Y N  
00093738756 MOXIFLOXACIN HCL moxifloxacin HCl TABLET 400 mg Y Y N  
00904740704 MOXIFLOXACIN HCL moxifloxacin HCl TABLET 400 mg Y Y N  
00904740706 MOXIFLOXACIN HCL moxifloxacin HCl TABLET 400 mg Y Y N  
50268057611 MOXIFLOXACIN HCL moxifloxacin HCl TABLET 400 mg Y Y N  
50268057613 MOXIFLOXACIN HCL moxifloxacin HCl TABLET 400 mg Y Y N  
57237015630 MOXIFLOXACIN HCL moxifloxacin HCl TABLET 400 mg Y Y N  
65862060330 MOXIFLOXACIN HCL moxifloxacin HCl TABLET 400 mg Y Y N  
68084072211 MOXIFLOXACIN HCL moxifloxacin HCl TABLET 400 mg Y Y N  
68084072265 MOXIFLOXACIN HCL moxifloxacin HCl TABLET 400 mg Y Y N  
72205000130 MOXIFLOXACIN HCL moxifloxacin HCl TABLET 400 mg Y Y N  
75834020050 OFLOXACIN ofloxacin TABLET 300 mg N Y N  
75834020101 OFLOXACIN ofloxacin TABLET 400 mg N Y N  
75834020150 OFLOXACIN ofloxacin TABLET 400 mg N Y N  
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