Tetracyclines, Parenteral

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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
63323013002 DOXY 100 doxycycline hyclate VIAL 100 mg Y N  
63323013003 DOXY 100 doxycycline hyclate VIAL 100 mg Y N  
63323013011 DOXY 100 doxycycline hyclate VIAL 100 mg Y N  
63323013013 DOXY 100 doxycycline hyclate VIAL 100 mg Y N  
63323013017 DOXY 100 doxycycline hyclate VIAL 100 mg Y N  
63323013041 DOXY 100 doxycycline hyclate VIAL 100 mg Y N  
00143938101 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
00143938110 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
16714064401 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
16714064410 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
42023024401 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
42023024410 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
43598008611 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
43598008658 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
66794023702 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
66794023741 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
67457043700 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
67457043710 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
68382091001 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
68382091010 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
70436003235 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
70436003282 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
70748033801 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
70748033810 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
71288003020 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
71288003021 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
72266023701 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
72266023705 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
83634011120 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
83634011141 DOXYCYCLINE HYCLATE doxycycline hyclate VIAL 100 mg Y N  
43538060130 MORGIDOX doxycycline/skin cleanser no19 KIT 100 mg Y N  
43538061160 MORGIDOX doxycycline/skin cleanser no19 KIT 100 mg Y N  
43538062130 MORGIDOX doxycycline/skin cleanser no19 KIT 50 mg N Y N  
71773010005 XERAVA eravacycline di-hydrochloride VIAL 100 mg Y N  
71773010012 XERAVA eravacycline di-hydrochloride VIAL 100 mg Y N  
71773005001 XERAVA eravacycline di-hydrochloride VIAL 50 mg Y N  
71773005005 XERAVA eravacycline di-hydrochloride VIAL 50 mg Y N  
71773005012 XERAVA eravacycline di-hydrochloride VIAL 50 mg Y N  
70842016001 MINOCIN minocycline HCl VIAL 100 mg Y N  
70842016010 MINOCIN minocycline HCl VIAL 100 mg Y N  
71715000101 NUZYRA omadacycline tosylate VIAL 100 mg Y N  
71715000102 NUZYRA omadacycline tosylate VIAL 100 mg Y N  
00049076009 TERRAMYCIN IM oxytetracycline AMPUL 100 mg/2 mL Y N  
00049077009 TERRAMYCIN oxytetracycline AMPUL 250 mg/2 mL Y N  
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