Urinary Antibacterials, Analgesics

← Back to Class List

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.

< Return to summary view

NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00173092245 BLUJEPA gepotidacin mesylate TABLET 750 mg N Y N  
00143931501 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 250 mg/50 mL Y N  
00143931524 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 250 mg/50 mL Y N  
00143972201 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 250 mg/50 mL Y N  
00143972224 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 250 mg/50 mL Y N  
00409052813 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 250 mg/50 mL Y N  
00409052815 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 250 mg/50 mL Y N  
00409222001 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 250 mg/50 mL Y N  
00409222024 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 250 mg/50 mL Y N  
25021013281 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 250 mg/50 mL Y N  
36000004624 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 250 mg/50 mL Y N  
44567043524 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 250 mg/50 mL Y N  
00143931601 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 500 mg/100 mL Y N  
00143931624 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 500 mg/100 mL Y N  
00143972101 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 500 mg/100 mL Y N  
00143972124 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 500 mg/100 mL Y N  
00409052823 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 500 mg/100 mL Y N  
00409052825 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 500 mg/100 mL Y N  
00409333001 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 500 mg/100 mL Y N  
00409333024 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 500 mg/100 mL Y N  
25021013282 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 500 mg/100 mL Y N  
36000004724 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 500 mg/100 mL Y N  
44567043624 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 500 mg/100 mL Y N  
00143931701 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 750 mg/150 mL Y N  
00143931724 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 750 mg/150 mL Y N  
00143972001 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 750 mg/150 mL Y N  
00143972024 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 750 mg/150 mL Y N  
00409052831 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 750 mg/150 mL Y N  
00409052835 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 750 mg/150 mL Y N  
00409444401 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 750 mg/150 mL Y N  
00409444424 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 750 mg/150 mL Y N  
25021013283 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 750 mg/150 mL Y N  
44567043724 LEVOFLOXACIN-D5W levofloxacin in dextrose 5 % PIGGYBACK 750 mg/150 mL Y N  
00178074001 URIBEL meth/meblue/sod phos/psal/hyos CAPSULE 118 mg-10 mg-40.8 mg-36 mg-0.12 mg Y N  
58657045601 URO-MP meth/meblue/sod phos/psal/hyos CAPSULE 118 mg-10 mg-40.8 mg-36 mg-0.12 mg Y N  
44523074301 USTELL meth/meblue/sod phos/psal/hyos CAPSULE 120 mg-10 mg-40.8 mg-36 mg-0.12 mg Y N  
28595029960 MB CAPS meth/meblue/sod phos/psal/hyos CAPSULE 120 mg-10.8 mg-40.8 mg-36.2 mg-0.12 mg Y N  
28595022460 URIMAR-T meth/meblue/sod phos/psal/hyos CAPSULE 120 mg-10.8 mg-40.8 mg-36.2 mg-0.12 mg Y N  
00037632190 URELLE meth/meblue/sod phos/psal/hyos TABLET 81 mg-10.8 mg-40.8 mg-32.4 mg-0.12 mg Y N  
44523074201 PHOSPHASAL meth/meblue/sod phos/psal/hyos TABLET 81.6 mg-10.8 mg-40.8 mg-36.2 mg-0.12 mg Y N  
00178051301 UTIRA-C meth/meblue/sod phos/psal/hyos TABLET 81.6 mg-10.8 mg-40.8 mg-36.2 mg-0.12 mg Y N  
44523074101 HYOPHEN methenam/m.blue/salicyl/hyoscy TABLET 81.6 mg-10.8 mg-9 mg-36.2 mg-0.12 mg Y N  
00178074501 URIBEL TABS methenam/m.blue/salicyl/hyoscy TABLET 81.6 mg-10.8 mg-9 mg-36.2 mg-0.12 mg Y N  
58657045401 ME-NAPHOS-MB-HYO 1 methenam/sod phos/mblue/hyoscy TABLET 81.6 mg-40.8 mg-10.8 mg-0.12 mg Y N  
00485015101 UROGESIC-BLUE methenam/sod phos/mblue/hyoscy TABLET 81.6 mg-40.8 mg-10.8 mg-0.12 mg Y N  
00485015130 UROGESIC-BLUE methenam/sod phos/mblue/hyoscy TABLET 81.6 mg-40.8 mg-10.8 mg-0.12 mg Y N  
42571033201 METHENAMINE HIPPURATE methenamine hippurate TABLET 1 gram Y N  
47781057701 METHENAMINE HIPPURATE methenamine hippurate TABLET 1 gram Y N  
50268054911 METHENAMINE HIPPURATE methenamine hippurate TABLET 1 gram Y N  
50268054915 METHENAMINE HIPPURATE methenamine hippurate TABLET 1 gram Y N  
50742014201 METHENAMINE HIPPURATE methenamine hippurate TABLET 1 gram Y N  
59746079701 METHENAMINE HIPPURATE methenamine hippurate TABLET 1 gram Y N  
60687069411 METHENAMINE HIPPURATE methenamine hippurate TABLET 1 gram Y N  
60687069421 METHENAMINE HIPPURATE methenamine hippurate TABLET 1 gram Y N  
65862078201 METHENAMINE HIPPURATE methenamine hippurate TABLET 1 gram Y N  
72578017501 METHENAMINE HIPPURATE methenamine hippurate TABLET 1 gram Y N  
72603081601 METHENAMINE HIPPURATE methenamine hippurate TABLET 1 gram Y N  
42799010601 METHENAMINE MANDELATE methenamine mandelate TABLET 1 gram Y N  
62135020112 METHENAMINE MANDELATE methenamine mandelate TABLET 1 gram Y N  
62135020160 METHENAMINE MANDELATE methenamine mandelate TABLET 1 gram Y N  
42799010501 METHENAMINE MANDELATE methenamine mandelate TABLET 500 mg Y N  
62135020012 METHENAMINE MANDELATE methenamine mandelate TABLET 500 mg Y N  
62135020060 METHENAMINE MANDELATE methenamine mandelate TABLET 500 mg Y N  
46122062262 ANTIBACTERIAL-URINARY PAIN RLF methenamine/sodium salicylate TABLET 162 mg-162.5 mg Y N  
57237033242 URO-PAIN DUAL ACTION methenamine/sodium salicylate TABLET 162 mg-162.5 mg Y N  
00121199610 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
00121199695 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
00472199208 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
16571074024 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
43386045011 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
59651020623 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
64980059324 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
69238251209 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
70069082901 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
70377011831 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
70954049610 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
72603017601 NITROFURANTOIN nitrofurantoin ORAL SUSP 25 mg/5 mL Y N  
16571088806 NITROFURANTOIN nitrofurantoin ORAL SUSP 50 mg/5 mL Y N  
00115164501 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
43386064201 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
50268062411 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
50268062415 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
57664023388 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
59651079501 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
60687031601 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
60687031611 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
60687085001 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
60687085011 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
62332039131 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
68001060500 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
70756041211 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
72603018401 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
62584080801 NITROFURANTOIN MACROCRYSTAL nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
62584080833 NITROFURANTOIN MACROCRYSTAL nitrofurantoin macrocrystal CAPSULE 100 mg Y N  
57664023188 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 25 mg Y N  
62332038931 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 25 mg Y N  
68001060300 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 25 mg Y N  
70756041011 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 25 mg Y N  
72603018201 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 25 mg Y N  
00115164301 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
00115202310 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
00904702661 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
43386064101 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
50268062311 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
50268062315 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
57664023288 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
59651075301 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
60687083901 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
60687083911 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
62332039031 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
68001060400 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
68382055901 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
70756041111 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
72603018301 NITROFURANTOIN nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
62584067301 NITROFURANTOIN MACROCRYSTAL nitrofurantoin macrocrystal CAPSULE 50 mg Y N  
52427028501 MACROBID nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
00185012201 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
00185012210 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
00591365801 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
00904713761 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
13811071910 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
47781030301 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
50268062511 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
50268062515 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
59746076201 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
59746076206 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
60687063301 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
60687063311 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
60687063365 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
65162047810 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
65862092901 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
68001042300 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
68001060600 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
70756040411 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
72603019601 NITROFURANTOIN MONO-MACRO nitrofurantoin monohyd/m-cryst CAPSULE 100 mg Y N  
Back to Top ↑