Antimalarials
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 00078056845 | COARTEM | artemether/lumefantrine | TABLET | 20 mg-120 mg | Y | N | ||
| 73607000201 | ARTESUNATE | artesunate | VIAL | 110 mg | Y | N | ||
| 73607001111 | ARTESUNATE | artesunate | VIAL | 110 mg | Y | N | ||
| 00378416201 | ATOVAQUONE-PROGUANIL HCL | atovaquone/proguanil HCl | TABLET | 250 mg-100 mg | Y | N | ||
| 66993006002 | ATOVAQUONE-PROGUANIL HCL | atovaquone/proguanil HCl | TABLET | 250 mg-100 mg | Y | N | ||
| 66993006027 | ATOVAQUONE-PROGUANIL HCL | atovaquone/proguanil HCl | TABLET | 250 mg-100 mg | Y | N | ||
| 68001024500 | ATOVAQUONE-PROGUANIL HCL | atovaquone/proguanil HCl | TABLET | 250 mg-100 mg | Y | N | ||
| 68001024514 | ATOVAQUONE-PROGUANIL HCL | atovaquone/proguanil HCl | TABLET | 250 mg-100 mg | Y | N | ||
| 68001024515 | ATOVAQUONE-PROGUANIL HCL | atovaquone/proguanil HCl | TABLET | 250 mg-100 mg | Y | N | ||
| 68462040401 | ATOVAQUONE-PROGUANIL HCL | atovaquone/proguanil HCl | TABLET | 250 mg-100 mg | Y | N | ||
| 68462040444 | ATOVAQUONE-PROGUANIL HCL | atovaquone/proguanil HCl | TABLET | 250 mg-100 mg | Y | N | ||
| 68462040467 | ATOVAQUONE-PROGUANIL HCL | atovaquone/proguanil HCl | TABLET | 250 mg-100 mg | Y | N | ||
| 00173067501 | MALARONE | atovaquone/proguanil HCl | TABLET | 250 mg-100 mg | Y | N | ||
| 00173067502 | MALARONE | atovaquone/proguanil HCl | TABLET | 250 mg-100 mg | Y | N | ||
| 00378416001 | ATOVAQUONE-PROGUANIL HCL | atovaquone/proguanil HCl | TABLET | 62.5 mg-25 mg (pediatric) | Y | N | ||
| 68462040201 | ATOVAQUONE-PROGUANIL HCL | atovaquone/proguanil HCl | TABLET | 62.5 mg-25 mg (pediatric) | Y | N | ||
| 00173067601 | MALARONE | atovaquone/proguanil HCl | TABLET | 62.5 mg-25 mg (pediatric) | Y | N | ||
| 64980017750 | CHLOROQUINE PHOSPHATE | chloroquine phosphate | TABLET | 250 mg | Y | N | ||
| 76385014205 | CHLOROQUINE PHOSPHATE | chloroquine phosphate | TABLET | 250 mg | Y | N | ||
| 00115701009 | CHLOROQUINE PHOSPHATE | chloroquine phosphate | TABLET | 500 mg | Y | N | ||
| 23155085074 | CHLOROQUINE PHOSPHATE | chloroquine phosphate | TABLET | 500 mg | Y | N | ||
| 62135071726 | CHLOROQUINE PHOSPHATE | chloroquine phosphate | TABLET | 500 mg | Y | N | ||
| 64980017802 | CHLOROQUINE PHOSPHATE | chloroquine phosphate | TABLET | 500 mg | Y | N | ||
| 00007419518 | HALFAN | halofantrine HCl | TABLET | 250 mg | Y | N | ||
| 43598013301 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 100 mg | Y | N | ||
| 00093240101 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 00904704606 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 00904704661 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 16571011201 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 16571011250 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 16571068701 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 16571068750 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 16714011001 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 16714011002 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 16729048501 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 16729048516 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 43598072101 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 43598072105 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 50268041211 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 50268041215 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 59651088901 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 59651088905 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 62135075290 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 68084026901 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 68084026911 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 68382009601 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 68382009605 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 69238154401 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 69238154405 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 76385014401 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 76385014450 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 82009004505 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 83980000101 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 83980000105 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 70954080420 | SOVUNA | hydroxychloroquine sulfate | TABLET | 200 mg | Y | N | ||
| 43598013201 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 300 mg | Y | N | ||
| 70954080510 | SOVUNA | hydroxychloroquine sulfate | TABLET | 300 mg | Y | N | ||
| 43598013101 | HYDROXYCHLOROQUINE SULFATE | hydroxychloroquine sulfate | TABLET | 400 mg | Y | N | ||
| 00555017178 | MEFLOQUINE HCL | mefloquine HCl | TABLET | 250 mg | Y | N | ||
| 00555017188 | MEFLOQUINE HCL | mefloquine HCl | TABLET | 250 mg | Y | N | ||
| 62135097325 | MEFLOQUINE HCL | mefloquine HCl | TABLET | 250 mg | Y | N | ||
| 00024159601 | PRIMAQUINE | primaquine phosphate | TABLET | 26.3 mg (15 mg base) | Y | N | ||
| 50742019105 | PRIMAQUINE | primaquine phosphate | TABLET | 26.3 mg (15 mg base) | Y | N | ||
| 76385010201 | PRIMAQUINE | primaquine phosphate | TABLET | 26.3 mg (15 mg base) | Y | N | ||
| 00480372001 | PYRIMETHAMINE | pyrimethamine | TABLET | 25 mg | Y | N | ||
| 00480372056 | PYRIMETHAMINE | pyrimethamine | TABLET | 25 mg | Y | N | ||
| 43598067201 | PYRIMETHAMINE | pyrimethamine | TABLET | 25 mg | Y | N | ||
| 43598067230 | PYRIMETHAMINE | pyrimethamine | TABLET | 25 mg | Y | N | ||
| 59651059001 | PYRIMETHAMINE | pyrimethamine | TABLET | 25 mg | Y | N | ||
| 72603026201 | PYRIMETHAMINE | pyrimethamine | TABLET | 25 mg | Y | N | ||
| 72603026202 | PYRIMETHAMINE | pyrimethamine | TABLET | 25 mg | Y | N | ||
| 00093300256 | QUININE SULFATE | quinine sulfate | CAPSULE | 324 mg | Y | N | ||
| 50742023830 | QUININE SULFATE | quinine sulfate | CAPSULE | 324 mg | Y | N | ||
| 68180056006 | QUININE SULFATE | quinine sulfate | CAPSULE | 324 mg | Y | N | ||
| 53746025001 | QUININE SULFATE | quinine sulfate | TABLET | 260 mg | Y | N | ||
| 53746025010 | QUININE SULFATE | quinine sulfate | TABLET | 260 mg | Y | N | ||
| 00173088939 | KRINTAFEL | tafenoquine succinate | TABLET | 150 mg | Y | N |