Antidiarrheals

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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
00363037502 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
00363037506 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
00363037507 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
00363037508 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
00363037522 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
00363037545 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
00363037546 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
10939023633 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
10939037433 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
10960070112 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
11822318460 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
11822331370 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
11822333780 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
11822351990 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
11917005591 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
11917005592 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
11917005594 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
11917005640 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
11917013288 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
11917013427 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
11917014910 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
30142099823 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
30142099862 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
30142099867 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
34575051892 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
34575069860 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
35515099640 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
36800022453 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
36800022462 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
36800022480 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
36800022491 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
41163025574 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
41163037544 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
41250022453 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
43072000296 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
43072000297 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
43292056079 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
49035022402 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
49035022416 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
49035022423 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
49035022482 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
52569013546 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
52569013547 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
57896038113 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
57896038125 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
59779022467 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
59779022480 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
59779070053 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
59779070082 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
59779096062 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
63868055912 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
70030013216 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
70030013217 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
70030014966 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
71205007912 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
81131002246 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
81131010679 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
81131018403 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
81131029776 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
81131069989 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
81131073145 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
87701011896 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
87701079188 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
87701079212 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y N Quantity Limit
00113022453 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
00113022462 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
00113022491 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
00113222462 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
00113222468 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Quantity Limit
00904772512 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
00904772524 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
24385055453 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
24385055462 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
46122073853 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
46122073862 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
49348052902 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
49348052904 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
70000058901 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
70677110601 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
70677110602 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
83324006412 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
83324006424 ANTI-DIARRHEAL loperamide HCl TABLET 2 mg Y Y Quantity Limit
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