Mycobacterium drugs

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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
59676070101 SIRTURO bedaquiline fumarate TABLET 100 mg Y N  
59676070260 SIRTURO bedaquiline fumarate TABLET 20 mg Y N  
33342046266 CYCLOSERINE cycloserine CAPSULE 250 mg Y N  
43598023510 CYCLOSERINE cycloserine CAPSULE 250 mg Y N  
43598023531 CYCLOSERINE cycloserine CAPSULE 250 mg Y N  
42806010101 ETHAMBUTOL HCL ethambutol HCl TABLET 100 mg Y N  
54879000101 ETHAMBUTOL HCL ethambutol HCl TABLET 100 mg Y N  
68180028001 ETHAMBUTOL HCL ethambutol HCl TABLET 100 mg Y N  
42806010201 ETHAMBUTOL HCL ethambutol HCl TABLET 400 mg Y N  
54879000201 ETHAMBUTOL HCL ethambutol HCl TABLET 400 mg Y N  
68084028001 ETHAMBUTOL HCL ethambutol HCl TABLET 400 mg Y N  
68084028011 ETHAMBUTOL HCL ethambutol HCl TABLET 400 mg Y N  
68180028101 ETHAMBUTOL HCL ethambutol HCl TABLET 400 mg Y N  
00008411701 TRECATOR ethionamide TABLET 250 mg Y N  
46287000901 ISONIAZID isoniazid SOLUTION 50 mg/5 mL Y N  
62135055047 ISONIAZID isoniazid SOLUTION 50 mg/5 mL Y N  
00555006602 ISONIAZID isoniazid TABLET 100 mg Y N  
64950021610 ISONIAZID isoniazid TABLET 100 mg Y N  
81665010710 ISONIAZID isoniazid TABLET 100 mg Y N  
00555007101 ISONIAZID isoniazid TABLET 300 mg Y N  
00555007102 ISONIAZID isoniazid TABLET 300 mg Y N  
51079008301 ISONIAZID isoniazid TABLET 300 mg Y N  
51079008320 ISONIAZID isoniazid TABLET 300 mg Y N  
60687055301 ISONIAZID isoniazid TABLET 300 mg Y N  
60687055311 ISONIAZID isoniazid TABLET 300 mg Y N  
62135070990 ISONIAZID isoniazid TABLET 300 mg Y N  
64950021703 ISONIAZID isoniazid TABLET 300 mg Y N  
64950021710 ISONIAZID isoniazid TABLET 300 mg Y N  
81665010810 ISONIAZID isoniazid TABLET 300 mg Y N  
81665010830 ISONIAZID isoniazid TABLET 300 mg Y N  
49502047626 PRETOMANID pretomanid TABLET 200 mg Y N  
00054081221 PYRAZINAMIDE pyrazinamide TABLET 500 mg Y N  
00054081222 PYRAZINAMIDE pyrazinamide TABLET 500 mg Y N  
00054081225 PYRAZINAMIDE pyrazinamide TABLET 500 mg Y N  
00054081229 PYRAZINAMIDE pyrazinamide TABLET 500 mg Y N  
33342044711 PYRAZINAMIDE pyrazinamide TABLET 500 mg Y N  
33342044715 PYRAZINAMIDE pyrazinamide TABLET 500 mg Y N  
60687078901 PYRAZINAMIDE pyrazinamide TABLET 500 mg Y N  
60687078911 PYRAZINAMIDE pyrazinamide TABLET 500 mg Y N  
70954048410 PYRAZINAMIDE pyrazinamide TABLET 500 mg Y N  
70954048420 PYRAZINAMIDE pyrazinamide TABLET 500 mg Y N  
70954048430 PYRAZINAMIDE pyrazinamide TABLET 500 mg Y N  
59762135001 RIFABUTIN rifabutin CAPSULE 150 mg Y N  
70954004110 RIFABUTIN rifabutin CAPSULE 150 mg Y N  
24658080130 RIFAMPIN rifampin CAPSULE 150 mg Y N  
42806080101 RIFAMPIN rifampin CAPSULE 150 mg Y N  
42806080130 RIFAMPIN rifampin CAPSULE 150 mg Y N  
60687057511 RIFAMPIN rifampin CAPSULE 150 mg Y N  
60687057521 RIFAMPIN rifampin CAPSULE 150 mg Y N  
62135031530 RIFAMPIN rifampin CAPSULE 150 mg Y N  
68180065806 RIFAMPIN rifampin CAPSULE 150 mg Y N  
00904731561 RIFAMPIN rifampin CAPSULE 300 mg Y N  
24658080260 RIFAMPIN rifampin CAPSULE 300 mg Y N  
42806079901 RIFAMPIN rifampin CAPSULE 300 mg Y N  
42806079930 RIFAMPIN rifampin CAPSULE 300 mg Y N  
42806079960 RIFAMPIN rifampin CAPSULE 300 mg Y N  
60687058601 RIFAMPIN rifampin CAPSULE 300 mg Y N  
60687058611 RIFAMPIN rifampin CAPSULE 300 mg Y N  
62135031660 RIFAMPIN rifampin CAPSULE 300 mg Y N  
68180065906 RIFAMPIN rifampin CAPSULE 300 mg Y N  
68180065907 RIFAMPIN rifampin CAPSULE 300 mg Y N  
00088210201 PRIFTIN rifapentine TABLET 150 mg Y N  
00088210224 PRIFTIN rifapentine TABLET 150 mg Y N  
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