Hyoscyamine
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 62135051352 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | DROPS | 0.125 mg/mL | N | Y | N | |
| 62135051147 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | ELIXIR | 125 mcg/5 mL | Y | Y | N | |
| 00115702501 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TAB ER 12H | 0.375 mg | N | Y | N | |
| 39328005210 | HYOSCYAMINE SULFATE ER | hyoscyamine sulfate | TAB ER 12H | 0.375 mg | N | Y | N | |
| 47781001401 | HYOSCYAMINE SULFATE ER | hyoscyamine sulfate | TAB ER 12H | 0.375 mg | N | Y | N | |
| 51525011501 | HYOSCYAMINE SULFATE ER | hyoscyamine sulfate | TAB ER 12H | 0.375 mg | N | Y | N | |
| 62559042301 | HYOSCYAMINE SULFATE ER | hyoscyamine sulfate | TAB ER 12H | 0.375 mg | N | Y | N | |
| 00485008201 | ED-SPAZ | hyoscyamine sulfate | TAB RAPDIS | 0.125 mg | Y | Y | N | |
| 39328004910 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TAB RAPDIS | 0.125 mg | Y | Y | N | |
| 42192033801 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TAB RAPDIS | 0.125 mg | Y | Y | N | |
| 62559042201 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TAB RAPDIS | 0.125 mg | Y | Y | N | |
| 68220011810 | NULEV | hyoscyamine sulfate | TAB RAPDIS | 0.125 mg | Y | Y | N | |
| 00682070501 | MAR-SPAS | hyoscyamine sulfate | TAB RAPDIS | 0.25 mg | N | Y | N | |
| 39328005110 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TAB SUBL | 0.125 mg | Y | N | ||
| 42192033901 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TAB SUBL | 0.125 mg | Y | N | ||
| 47781001101 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TAB SUBL | 0.125 mg | Y | N | ||
| 62135085912 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TAB SUBL | 0.125 mg | Y | N | ||
| 62559042401 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TAB SUBL | 0.125 mg | Y | N | ||
| 68220011310 | LEVSIN-SL | hyoscyamine sulfate | TAB SUBL | 0.125 mg | Y | N | ||
| 68047025301 | OSCIMIN SL | hyoscyamine sulfate | TAB SUBL | 0.125 mg | Y | N | ||
| 39328005010 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TABLET | 0.125 mg | N | Y | N | |
| 42192034001 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TABLET | 0.125 mg | N | Y | N | |
| 62135051212 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TABLET | 0.125 mg | N | Y | N | |
| 62559042101 | HYOSCYAMINE SULFATE | hyoscyamine sulfate | TABLET | 0.125 mg | N | Y | N | |
| 68220011210 | LEVSIN | hyoscyamine sulfate | TABLET | 0.125 mg | N | Y | N | |
| 68047025201 | OSCIMIN | hyoscyamine sulfate | TABLET | 0.125 mg | N | Y | N | |
| 00682010601 | DONNAMAR | hyoscyamine sulfate | TABLET | 0.13 mg | N | Y | N |