Streptomycins

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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
00641616601 AMIKACIN SULFATE amikacin sulfate VIAL 1,000 mg/4 mL Y N  
00641616610 AMIKACIN SULFATE amikacin sulfate VIAL 1,000 mg/4 mL Y N  
23155029032 AMIKACIN SULFATE amikacin sulfate VIAL 1,000 mg/4 mL Y N  
23155029042 AMIKACIN SULFATE amikacin sulfate VIAL 1,000 mg/4 mL Y N  
23155078631 AMIKACIN SULFATE amikacin sulfate VIAL 1,000 mg/4 mL Y N  
23155078641 AMIKACIN SULFATE amikacin sulfate VIAL 1,000 mg/4 mL Y N  
25021017304 AMIKACIN SULFATE amikacin sulfate VIAL 1,000 mg/4 mL Y N  
63323081504 AMIKACIN SULFATE amikacin sulfate VIAL 1,000 mg/4 mL Y N  
63323081522 AMIKACIN SULFATE amikacin sulfate VIAL 1,000 mg/4 mL Y N  
83301002301 AMIKACIN SULFATE amikacin sulfate VIAL 1,000 mg/4 mL Y N  
83301002302 AMIKACIN SULFATE amikacin sulfate VIAL 1,000 mg/4 mL Y N  
00703902203 AMIKACIN SULFATE amikacin sulfate VIAL 50 mg/mL Y N  
00641616701 AMIKACIN SULFATE amikacin sulfate VIAL 500 mg/2 mL Y N  
00641616710 AMIKACIN SULFATE amikacin sulfate VIAL 500 mg/2 mL Y N  
23155029031 AMIKACIN SULFATE amikacin sulfate VIAL 500 mg/2 mL Y N  
23155029041 AMIKACIN SULFATE amikacin sulfate VIAL 500 mg/2 mL Y N  
23155078531 AMIKACIN SULFATE amikacin sulfate VIAL 500 mg/2 mL Y N  
23155078541 AMIKACIN SULFATE amikacin sulfate VIAL 500 mg/2 mL Y N  
25021017302 AMIKACIN SULFATE amikacin sulfate VIAL 500 mg/2 mL Y N  
63323081502 AMIKACIN SULFATE amikacin sulfate VIAL 500 mg/2 mL Y N  
63323081521 AMIKACIN SULFATE amikacin sulfate VIAL 500 mg/2 mL Y N  
83301002201 AMIKACIN SULFATE amikacin sulfate VIAL 500 mg/2 mL Y N  
83301002202 AMIKACIN SULFATE amikacin sulfate VIAL 500 mg/2 mL Y N  
00338050548 GENTAMICIN SULFATE IN NS gentamicin in NaCl, iso-osm PIGGYBACK 100 mg/100 mL Y N  
00338051141 GENTAMICIN SULFATE IN NS gentamicin in NaCl, iso-osm PIGGYBACK 100 mg/50 mL Y N  
00338050748 GENTAMICIN SULFATE IN NS gentamicin in NaCl, iso-osm PIGGYBACK 120 mg/100 mL Y N  
00338050741 GENTAMICIN SULFATE IN NS gentamicin in NaCl, iso-osm PIGGYBACK 60 mg/50 mL Y N  
00409788113 GENTAMICIN SULFATE IN NS gentamicin in NaCl, iso-osm PIGGYBACK 70 mg/50 mL Y N  
00338050348 GENTAMICIN SULFATE IN NS gentamicin in NaCl, iso-osm PIGGYBACK 80 mg/100 mL Y N  
00338050941 GENTAMICIN SULFATE IN NS gentamicin in NaCl, iso-osm PIGGYBACK 80 mg/50 mL Y N  
00409788623 GENTAMICIN SULFATE IN NS gentamicin in NaCl, iso-osm PIGGYBACK 90 mg/100 mL Y N  
00143912801 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
00143912825 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
00409120703 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
00409120713 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
55150040201 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
55150040225 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
55150040301 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
55150040325 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
63323001001 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
63323001002 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
63323001003 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
63323001020 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
63323001041 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
63323001042 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
63323001094 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
63323001095 GENTAMICIN SULFATE gentamicin sulfate VIAL 40 mg/mL Y N  
55150040101 GENTAMICIN SULFATE gentamicin sulfate/PF VIAL 20 mg/2 mL Y N  
55150040125 GENTAMICIN SULFATE gentamicin sulfate/PF VIAL 20 mg/2 mL Y N  
63323017301 GENTAMICIN SULFATE gentamicin sulfate/PF VIAL 20 mg/2 mL Y N  
63323017302 GENTAMICIN SULFATE gentamicin sulfate/PF VIAL 20 mg/2 mL Y N  
63323017341 GENTAMICIN SULFATE gentamicin sulfate/PF VIAL 20 mg/2 mL Y N  
63323017394 GENTAMICIN SULFATE gentamicin sulfate/PF VIAL 20 mg/2 mL Y N  
00409340201 GENTAMICIN SULFATE gentamicin sulfate/PF VIAL PORT 100 mg/10 mL Y N  
00409340001 GENTAMICIN SULFATE gentamicin sulfate/PF VIAL PORT 60 mg/6 mL Y N  
00409340101 GENTAMICIN SULFATE gentamicin sulfate/PF VIAL PORT 80 mg/8 mL Y N  
00093117701 NEOMYCIN SULFATE neomycin sulfate TABLET 500 mg Y N  
62135044390 NEOMYCIN SULFATE neomycin sulfate TABLET 500 mg Y N  
73473090105 NEOMYCIN SULFATE neomycin sulfate TABLET 500 mg Y N  
69097082037 ZEMDRI plazomicin sulfate VIAL 500 mg/10 mL (50 mg/mL) Y N  
69097082096 ZEMDRI plazomicin sulfate VIAL 500 mg/10 mL (50 mg/mL) Y N  
39822070601 STREPTOMYCIN SULFATE streptomycin sulfate VIAL 1 gram Y N  
39822070602 STREPTOMYCIN SULFATE streptomycin sulfate VIAL 1 gram Y N  
39822041201 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
39822041206 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
63323030301 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
63323030351 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
63323030355 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
70436011036 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
70436011056 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
70436011080 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
70700017322 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
70700017386 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
72266016301 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
72266016306 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
72603016001 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
72603016006 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 1.2 gram Y N  
63323030501 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 10 mg/mL Y N  
63323030502 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 10 mg/mL Y N  
00409357801 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
00409357811 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
36000024201 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
36000024401 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
36000024425 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
63323030601 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
63323030602 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
63323030605 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
63323030626 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
63323030630 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
63323030751 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
67457042800 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
67457042830 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
67457047300 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
67457047322 TOBRAMYCIN SULFATE tobramycin sulfate VIAL 40 mg/mL Y N  
00002729301 NEBCIN tobramycin sulfate VIAL 60 mg Y N  
00338204948 NEBCIN IN DEXTROSE tobramycin sulfate/D5W PIGGYBACK 100 mg/100 mL Y N  
00338204541 NEBCIN IN DEXTROSE tobramycin sulfate/D5W PIGGYBACK 60 mg/50 mL Y N  
00338204748 NEBCIN IN DEXTROSE tobramycin sulfate/D5W PIGGYBACK 80 mg/100 mL Y N  
00409346913 TOBRAMYCIN SULFATE IN NS tobramycin/sodium chloride PIGGYBACK 60 mg/50 mL Y N  
00409653501 VANCOMYCIN HCL vancomycin HCl VIAL PORT 1 gram Y N  
00409653511 VANCOMYCIN HCL vancomycin HCl VIAL PORT 1 gram Y N  
00409653401 VANCOMYCIN HCL vancomycin HCl VIAL PORT 500 mg Y N  
00409653411 VANCOMYCIN HCL vancomycin HCl VIAL PORT 500 mg Y N  
00409653101 VANCOMYCIN HCL vancomycin HCl VIAL PORT 750 mg Y N  
00409653111 VANCOMYCIN HCL vancomycin HCl VIAL PORT 750 mg Y N  
00338355248 VANCOMYCIN HCL vancomycin HCl in 5 % dextrose FROZ.PIGGY 1 gram/200 mL Y N  
00338012204 VANCOMYCIN HCL-D5W vancomycin HCl in 5 % dextrose FROZ.PIGGY 1.25 gram/250 mL Y N  
00338012404 VANCOMYCIN HCL-D5W vancomycin HCl in 5 % dextrose FROZ.PIGGY 1.5 gram/300 mL Y N  
00338355148 VANCOMYCIN HCL-D5W vancomycin HCl in 5 % dextrose FROZ.PIGGY 500 mg/100 mL Y N  
00338358048 VANCOMYCIN vancomycin HCl in 5 % dextrose FROZ.PIGGY 750 mg/150 mL Y N  
00338358301 VANCOMYCIN HCL-0.9% NACL vancomycin/0.9 % sod chloride FROZ.PIGGY 1 gram/200 mL Y N  
00338358101 VANCOMYCIN HCL-0.9% NACL vancomycin/0.9 % sod chloride FROZ.PIGGY 500 mg/100 mL Y N  
00338358201 VANCOMYCIN HCL-0.9% NACL vancomycin/0.9 % sod chloride FROZ.PIGGY 750 mg/150 mL Y N  
00143947201 TYZAVAN vancomycin/diluent no.2 (NADA) PIGGYBACK 1 gram/200 mL Y N  
00143947212 TYZAVAN vancomycin/diluent no.2 (NADA) PIGGYBACK 1 gram/200 mL Y N  
70594004201 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 1 gram/200 mL Y N  
70594004203 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 1 gram/200 mL Y N  
70594005701 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 1.25 gram/250 mL Y N  
70594005702 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 1.25 gram/250 mL Y N  
70594004301 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 1.5 gram/300 mL Y N  
70594004302 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 1.5 gram/300 mL Y N  
70594005801 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 1.75 gram/350 mL Y N  
70594005802 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 1.75 gram/350 mL Y N  
70594004401 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 2 gram/400 mL Y N  
70594004402 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 2 gram/400 mL Y N  
70594004101 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 500 mg/100 mL Y N  
70594004103 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 500 mg/100 mL Y N  
70594005601 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 750 mg/150 mL Y N  
70594005603 VANCOMYCIN HCL vancomycin/water for inj (PEG) PIGGYBACK 750 mg/150 mL Y N  
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