Antiparasitics

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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
00591271202 ALBENDAZOLE albendazole TABLET 200 mg Y N  
31722093502 ALBENDAZOLE albendazole TABLET 200 mg Y N  
42799011002 ALBENDAZOLE albendazole TABLET 200 mg Y N  
43598045202 ALBENDAZOLE albendazole TABLET 200 mg Y N  
72205005108 ALBENDAZOLE albendazole TABLET 200 mg Y N  
00121095608 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
00121101605 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
00121101618 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
00121101642 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
00904745925 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
00904745941 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
00904745953 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
10702022321 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
31722062921 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
60687053436 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
60687053440 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
60687053446 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
60687053452 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
60687053478 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
62135052809 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
62135052824 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
62135052845 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
63739020301 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
63739020302 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
63739020303 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
65162069388 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
68462042121 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
68462042169 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
69452025287 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
70748029901 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
72603024801 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
81033010405 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
81033010422 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
81033010442 ATOVAQUONE atovaquone ORAL SUSP 750 mg/5 mL Y N  
00173054700 MEPRON atovaquone ORAL SUSP 750 mg/5 mL Y N  
00173066518 MEPRON atovaquone ORAL SUSP 750 mg/5 mL Y N  
00642746410 BENZNIDAZOLE benznidazole TABLET 100 mg Y N  
00642746312 BENZNIDAZOLE benznidazole TABLET 12.5 mg Y N  
62135096630 DAPSONE dapsone TABLET 100 mg Y N  
64980056601 DAPSONE dapsone TABLET 100 mg Y N  
64980056603 DAPSONE dapsone TABLET 100 mg Y N  
69367037901 DAPSONE dapsone TABLET 100 mg Y N  
69367037930 DAPSONE dapsone TABLET 100 mg Y N  
69367041001 DAPSONE dapsone TABLET 100 mg Y N  
69367041030 DAPSONE dapsone TABLET 100 mg Y N  
70954013610 DAPSONE dapsone TABLET 100 mg Y N  
70954013620 DAPSONE dapsone TABLET 100 mg Y N  
62135096530 DAPSONE dapsone TABLET 25 mg Y N  
64980056701 DAPSONE dapsone TABLET 25 mg Y N  
64980056703 DAPSONE dapsone TABLET 25 mg Y N  
69367037801 DAPSONE dapsone TABLET 25 mg Y N  
69367037830 DAPSONE dapsone TABLET 25 mg Y N  
69367040901 DAPSONE dapsone TABLET 25 mg Y N  
69367040930 DAPSONE dapsone TABLET 25 mg Y N  
70954013510 DAPSONE dapsone TABLET 25 mg Y N  
70954013520 DAPSONE dapsone TABLET 25 mg Y N  
42799080601 IVERMECTIN ivermectin TABLET 3 mg Y N  
72888020608 IVERMECTIN ivermectin TABLET 3 mg Y N  
72888020666 IVERMECTIN ivermectin TABLET 3 mg Y N  
75907016721 IVERMECTIN ivermectin TABLET 3 mg Y N  
00006003201 STROMECTOL ivermectin TABLET 3 mg Y N  
00006003220 STROMECTOL ivermectin TABLET 3 mg Y N  
00006003299 STROMECTOL ivermectin TABLET 3 mg Y N  
72888020708 IVERMECTIN ivermectin TABLET 6 mg Y N  
72888020766 IVERMECTIN ivermectin TABLET 6 mg Y N  
00006013910 STROMECTOL ivermectin TABLET 6 mg Y N  
64896066930 EMVERM mebendazole TAB CHEW 100 mg Y N  
00264553532 METRO IV metronidazole/sodium chloride PIGGYBACK 500 mg/100 mL Y N  
00338105548 METRONIDAZOLE metronidazole/sodium chloride PIGGYBACK 500 mg/100 mL Y N  
00338954124 METRONIDAZOLE metronidazole/sodium chloride PIGGYBACK 500 mg/100 mL Y N  
00409015201 METRONIDAZOLE metronidazole/sodium chloride PIGGYBACK 500 mg/100 mL Y N  
00409015224 METRONIDAZOLE metronidazole/sodium chloride PIGGYBACK 500 mg/100 mL Y N  
25021013182 METRONIDAZOLE metronidazole/sodium chloride PIGGYBACK 500 mg/100 mL Y N  
44567072001 METRONIDAZOLE metronidazole/sodium chloride PIGGYBACK 500 mg/100 mL Y N  
44567072024 METRONIDAZOLE metronidazole/sodium chloride PIGGYBACK 500 mg/100 mL Y N  
44567075001 METRONIDAZOLE metronidazole/sodium chloride PIGGYBACK 500 mg/100 mL Y N  
44567075024 METRONIDAZOLE metronidazole/sodium chloride PIGGYBACK 500 mg/100 mL Y N  
47335099301 METRONIDAZOLE metronidazole/sodium chloride PIGGYBACK 500 mg/100 mL Y N  
50419075101 LAMPIT nifurtimox TABLET 120 mg Y N  
50419075001 LAMPIT nifurtimox TABLET 30 mg Y N  
64980052603 NITAZOXANIDE nitazoxanide TABLET 500 mg Y N  
64980052621 NITAZOXANIDE nitazoxanide TABLET 500 mg Y N  
64980052660 NITAZOXANIDE nitazoxanide TABLET 500 mg Y N  
64980052681 NITAZOXANIDE nitazoxanide TABLET 500 mg Y N  
70954093410 NITAZOXANIDE nitazoxanide TABLET 500 mg Y N  
23155003801 PAROMOMYCIN SULFATE paromomycin sulfate CAPSULE 250 mg Y N  
63323011301 PENTAM 300 pentamidine isethionate VIAL 300 mg Y N  
63323011310 PENTAM 300 pentamidine isethionate VIAL 300 mg Y N  
00074454801 PENTAMIDINE ISETHIONATE pentamidine isethionate VIAL 300 mg Y N  
13925051501 PENTAMIDINE ISETHIONATE pentamidine isethionate VIAL 300 mg Y N  
13925051510 PENTAMIDINE ISETHIONATE pentamidine isethionate VIAL 300 mg Y N  
23155074831 PENTAMIDINE ISETHIONATE pentamidine isethionate VIAL 300 mg Y N  
23155074841 PENTAMIDINE ISETHIONATE pentamidine isethionate VIAL 300 mg Y N  
39822305001 PENTAMIDINE ISETHIONATE pentamidine isethionate VIAL 300 mg Y N  
39822305002 PENTAMIDINE ISETHIONATE pentamidine isethionate VIAL 300 mg Y N  
63323087715 NEBUPENT pentamidine isethionate VIAL-NEB 300 mg Y N  
13925052201 PENTAMIDINE ISETHIONATE pentamidine isethionate VIAL-NEB 300 mg Y N  
39822303001 PENTAMIDINE ISETHIONATE pentamidine isethionate VIAL-NEB 300 mg Y N  
39822303002 PENTAMIDINE ISETHIONATE pentamidine isethionate VIAL-NEB 300 mg Y N  
49884023183 PRAZIQUANTEL praziquantel TABLET 600 mg Y N  
00078093791 EGATEN triclabendazole TABLET 250 mg Y N  
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