Antidotes

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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
00409330703 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
00409330711 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
00517750401 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
00517750425 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
42494043525 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
63323069122 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
63323069130 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
63323069310 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
63323069322 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
63323069504 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
63323069522 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
70069001801 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
70069001825 ACETYLCYSTEINE acetylcysteine VIAL 100 mg/mL (10 %) Y N  
66220020730 ACETADOTE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
00409330803 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
00409330811 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
00517760401 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
00517760425 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
00574080530 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
25021081230 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
25021081266 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
42494043625 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
55150025930 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323069022 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323069030 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323069041 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323069044 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323069210 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323069222 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323069404 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323069422 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323069441 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323069444 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323096321 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323096330 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323096341 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
63323096344 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
68462094612 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
68462094630 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
70069001901 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
70069001925 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
70069002001 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
70069002003 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
70069078801 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
70069078804 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
70594011101 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
70594011102 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
72611086001 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
72611086004 ACETYLCYSTEINE acetylcysteine VIAL 200 mg/mL (20 %) Y N  
00574052125 ACTIDOSE-AQUA activated charcoal ORAL SUSP 15 gram/72 mL Y N  
00574052174 ACTIDOSE-AQUA activated charcoal ORAL SUSP 25 gram/120 mL Y N  
66689020204 INSTA-CHAR activated charcoal ORAL SUSP 25 gram/120 mL Y N  
66689011308 INSTA-CHAR activated charcoal ORAL SUSP 25 gram/240 mL Y N  
66689011408 INSTA-CHAR activated charcoal ORAL SUSP 25 gram/240 mL Y N  
00574052176 ACTIDOSE-AQUA activated charcoal ORAL SUSP 50 gram/240 mL Y N  
66689020208 INSTA-CHAR activated charcoal ORAL SUSP 50 gram/240 mL Y N  
00574012225 EZ CHAR activated charcoal SUSP RECON 25 gram Y N  
00574052074 ACTIDOSE activated charcoal/sorbitol ORAL SUSP 25 gram/120 mL Y N  
66689020304 INSTA-CHAR activated charcoal/sorbitol ORAL SUSP 25 gram/120 mL Y N  
66689011508 INSTA-CHAR activated charcoal/sorbitol ORAL SUSP 25 gram/240 mL Y N  
00574052076 ACTIDOSE activated charcoal/sorbitol ORAL SUSP 50 gram/240 mL Y N  
66689020308 INSTA-CHAR activated charcoal/sorbitol ORAL SUSP 50 gram/240 mL Y N  
00006542402 ANTIVENIN LATRODECTUS MACTANS antivenin,Latrodectus mactans VIAL 6,000 unit Y N  
00008042301 ANTIVENIN MICRURUS FULVIUS antivenin,Micrurus fulvius VIAL Y N  
00008042303 ANTIVENIN MICRURUS FULVIUS antivenin,Micrurus fulvius VIAL Y N  
00143924701 DEXRAZOXANE dexrazoxane HCl VIAL 250 mg Y N  
55150043201 DEXRAZOXANE dexrazoxane HCl VIAL 250 mg Y N  
55150043202 DEXRAZOXANE dexrazoxane HCl VIAL 250 mg Y N  
55150043401 DEXRAZOXANE dexrazoxane HCl VIAL 250 mg Y N  
55150043402 DEXRAZOXANE dexrazoxane HCl VIAL 250 mg Y N  
72205024701 DEXRAZOXANE dexrazoxane HCl VIAL 250 mg Y N  
72266023501 DEXRAZOXANE dexrazoxane HCl VIAL 250 mg Y N  
00143924801 DEXRAZOXANE dexrazoxane HCl VIAL 500 mg Y N  
55150043501 DEXRAZOXANE dexrazoxane HCl VIAL 500 mg Y N  
55150043701 DEXRAZOXANE dexrazoxane HCl VIAL 500 mg Y N  
72205024801 DEXRAZOXANE dexrazoxane HCl VIAL 500 mg Y N  
72266010101 DEXRAZOXANE dexrazoxane HCl VIAL 500 mg Y N  
72611071601 DEXRAZOXANE dexrazoxane HCl VIAL 500 mg Y N  
72611071672 DEXRAZOXANE dexrazoxane HCl VIAL 500 mg Y N  
64980058805 EDETATE CALCIUM DISODIUM edetate calcium disodium VIAL 200 mg/mL Y N  
64980058851 EDETATE CALCIUM DISODIUM edetate calcium disodium VIAL 200 mg/mL Y N  
00517071001 FOMEPIZOLE fomepizole VIAL 1 gram/mL Y N  
25021082902 FOMEPIZOLE fomepizole VIAL 1 gram/mL Y N  
67457021102 FOMEPIZOLE fomepizole VIAL 1 gram/mL Y N  
70710147801 FOMEPIZOLE fomepizole VIAL 1 gram/mL Y N  
00054449705 LEUCOVORIN CALCIUM leucovorin calcium TABLET 10 mg Y N  
00054449710 LEUCOVORIN CALCIUM leucovorin calcium TABLET 10 mg Y N  
00054849706 LEUCOVORIN CALCIUM leucovorin calcium TABLET 10 mg Y N  
42806013321 LEUCOVORIN CALCIUM leucovorin calcium TABLET 10 mg Y N  
42806013324 LEUCOVORIN CALCIUM leucovorin calcium TABLET 10 mg Y N  
50742018212 LEUCOVORIN CALCIUM leucovorin calcium TABLET 10 mg Y N  
50742018224 LEUCOVORIN CALCIUM leucovorin calcium TABLET 10 mg Y N  
69315018512 LEUCOVORIN CALCIUM leucovorin calcium TABLET 10 mg Y N  
69315018524 LEUCOVORIN CALCIUM leucovorin calcium TABLET 10 mg Y N  
00054449805 LEUCOVORIN CALCIUM leucovorin calcium TABLET 15 mg Y N  
00054449810 LEUCOVORIN CALCIUM leucovorin calcium TABLET 15 mg Y N  
42806013424 LEUCOVORIN CALCIUM leucovorin calcium TABLET 15 mg Y N  
50742018324 LEUCOVORIN CALCIUM leucovorin calcium TABLET 15 mg Y N  
69315018624 LEUCOVORIN CALCIUM leucovorin calcium TABLET 15 mg Y N  
00054449911 LEUCOVORIN CALCIUM leucovorin calcium TABLET 25 mg Y N  
00555048527 LEUCOVORIN CALCIUM leucovorin calcium TABLET 25 mg Y N  
00904670310 LEUCOVORIN CALCIUM leucovorin calcium TABLET 25 mg Y N  
42806035925 LEUCOVORIN CALCIUM leucovorin calcium TABLET 25 mg Y N  
50742018425 LEUCOVORIN CALCIUM leucovorin calcium TABLET 25 mg Y N  
60687022711 LEUCOVORIN CALCIUM leucovorin calcium TABLET 25 mg Y N  
60687022794 LEUCOVORIN CALCIUM leucovorin calcium TABLET 25 mg Y N  
69315018725 LEUCOVORIN CALCIUM leucovorin calcium TABLET 25 mg Y N  
00054449613 LEUCOVORIN CALCIUM leucovorin calcium TABLET 5 mg Y N  
00054449625 LEUCOVORIN CALCIUM leucovorin calcium TABLET 5 mg Y N  
00054849619 LEUCOVORIN CALCIUM leucovorin calcium TABLET 5 mg Y N  
00555048401 LEUCOVORIN CALCIUM leucovorin calcium TABLET 5 mg Y N  
00555048402 LEUCOVORIN CALCIUM leucovorin calcium TABLET 5 mg Y N  
42806035801 LEUCOVORIN CALCIUM leucovorin calcium TABLET 5 mg Y N  
42806035830 LEUCOVORIN CALCIUM leucovorin calcium TABLET 5 mg Y N  
50742018101 LEUCOVORIN CALCIUM leucovorin calcium TABLET 5 mg Y N  
50742018130 LEUCOVORIN CALCIUM leucovorin calcium TABLET 5 mg Y N  
69315018401 LEUCOVORIN CALCIUM leucovorin calcium TABLET 5 mg Y N  
69315018403 LEUCOVORIN CALCIUM leucovorin calcium TABLET 5 mg Y N  
63323063110 LEUCOVORIN CALCIUM leucovorin calcium VIAL 10 mg/mL Y N  
63323063150 LEUCOVORIN CALCIUM leucovorin calcium VIAL 10 mg/mL Y N  
00143955401 LEUCOVORIN CALCIUM leucovorin calcium VIAL 100 mg Y N  
25021081430 LEUCOVORIN CALCIUM leucovorin calcium VIAL 100 mg Y N  
67457052810 LEUCOVORIN CALCIUM leucovorin calcium VIAL 100 mg Y N  
68001041636 LEUCOVORIN CALCIUM leucovorin calcium VIAL 100 mg Y N  
68001064836 LEUCOVORIN CALCIUM leucovorin calcium VIAL 100 mg Y N  
70436011780 LEUCOVORIN CALCIUM leucovorin calcium VIAL 100 mg Y N  
71288016120 LEUCOVORIN CALCIUM leucovorin calcium VIAL 100 mg Y N  
00143936801 LEUCOVORIN CALCIUM leucovorin calcium VIAL 200 mg Y N  
00143955301 LEUCOVORIN CALCIUM leucovorin calcium VIAL 200 mg Y N  
25021081530 LEUCOVORIN CALCIUM leucovorin calcium VIAL 200 mg Y N  
63323071050 LEUCOVORIN CALCIUM leucovorin calcium VIAL 200 mg Y N  
67457052920 LEUCOVORIN CALCIUM leucovorin calcium VIAL 200 mg Y N  
68001041737 LEUCOVORIN CALCIUM leucovorin calcium VIAL 200 mg Y N  
68001064937 LEUCOVORIN CALCIUM leucovorin calcium VIAL 200 mg Y N  
70436011880 LEUCOVORIN CALCIUM leucovorin calcium VIAL 200 mg Y N  
71288016230 LEUCOVORIN CALCIUM leucovorin calcium VIAL 200 mg Y N  
00143955201 LEUCOVORIN CALCIUM leucovorin calcium VIAL 350 mg Y N  
25021081630 LEUCOVORIN CALCIUM leucovorin calcium VIAL 350 mg Y N  
67457053035 LEUCOVORIN CALCIUM leucovorin calcium VIAL 350 mg Y N  
68001041838 LEUCOVORIN CALCIUM leucovorin calcium VIAL 350 mg Y N  
68001065038 LEUCOVORIN CALCIUM leucovorin calcium VIAL 350 mg Y N  
70436011980 LEUCOVORIN CALCIUM leucovorin calcium VIAL 350 mg Y N  
71288016330 LEUCOVORIN CALCIUM leucovorin calcium VIAL 350 mg Y N  
00143955501 LEUCOVORIN CALCIUM leucovorin calcium VIAL 50 mg Y N  
25021081310 LEUCOVORIN CALCIUM leucovorin calcium VIAL 50 mg Y N  
70436011682 LEUCOVORIN CALCIUM leucovorin calcium VIAL 50 mg Y N  
71288016010 LEUCOVORIN CALCIUM leucovorin calcium VIAL 50 mg Y N  
25021082850 LEUCOVORIN CALCIUM leucovorin calcium VIAL 500 mg Y N  
63323071100 LEUCOVORIN CALCIUM leucovorin calcium VIAL 500 mg Y N  
70436012080 LEUCOVORIN CALCIUM leucovorin calcium VIAL 500 mg Y N  
71288016450 LEUCOVORIN CALCIUM leucovorin calcium VIAL 500 mg Y N  
72893000401 KHAPZORY levoleucovorin VIAL 175 mg Y N  
70436020980 LEVOLEUCOVORIN CALCIUM levoleucovorin calcium VIAL 10 mg/mL Y N  
71288010518 LEVOLEUCOVORIN CALCIUM levoleucovorin calcium VIAL 10 mg/mL Y N  
72266012001 LEVOLEUCOVORIN CALCIUM levoleucovorin calcium VIAL 10 mg/mL Y N  
72266012101 LEVOLEUCOVORIN CALCIUM levoleucovorin calcium VIAL 10 mg/mL Y N  
71288010410 LEVOLEUCOVORIN CALCIUM levoleucovorin calcium VIAL 50 mg Y N  
50742035401 MESNA mesna TABLET 400 mg Y N  
50742035410 MESNA mesna TABLET 400 mg Y N  
67108356509 MESNEX mesna TABLET 400 mg Y N  
00143926001 MESNA mesna VIAL 100 mg/mL Y N  
10019095301 MESNA mesna VIAL 100 mg/mL Y N  
10019095362 MESNA mesna VIAL 100 mg/mL Y N  
25021020110 MESNA mesna VIAL 100 mg/mL Y N  
25021020111 MESNA mesna VIAL 100 mg/mL Y N  
63323073311 MESNA mesna VIAL 100 mg/mL Y N  
00338130501 MESNEX mesna VIAL 100 mg/mL Y N  
70121271502 METHYLENE BLUE methylene blue AMPUL 50 mg/10 mL (5 mg/mL) Y N  
70121271503 METHYLENE BLUE methylene blue AMPUL 50 mg/10 mL (5 mg/mL) Y N  
00517037401 PROVAYBLUE methylene blue AMPUL 50 mg/10 mL (5 mg/mL) Y N  
00517037405 PROVAYBLUE methylene blue AMPUL 50 mg/10 mL (5 mg/mL) Y N  
42494041901 METHYLENE BLUE methylene blue VIAL 1 % (10 mg/mL) Y N  
42494041905 METHYLENE BLUE methylene blue VIAL 1 % (10 mg/mL) Y N  
00143909401 METHYLENE BLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
00143909405 METHYLENE BLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
14789011905 METHYLENE BLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
14789011907 METHYLENE BLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
70700032822 METHYLENE BLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
70700032824 METHYLENE BLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
70710183801 METHYLENE BLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
70710183805 METHYLENE BLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
71288081110 METHYLENE BLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
71288081111 METHYLENE BLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
00517038101 PROVAYBLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
00517038105 PROVAYBLUE methylene blue VIAL 50 mg/10 mL (5 mg/mL) Y N  
60977014101 PROTOPAM CHLORIDE pralidoxime chloride VIAL 1 gram Y N  
60977014127 PROTOPAM CHLORIDE pralidoxime chloride VIAL 1 gram Y N  
55292020111 CHEMET succimer CAPSULE 100 mg Y N  
00591491001 TRIENTINE HCL trientine HCl CAPSULE 250 mg Y N  
16571081001 TRIENTINE HCL trientine HCl CAPSULE 250 mg Y N  
31722068301 TRIENTINE HCL trientine HCl CAPSULE 250 mg Y N  
43598045901 TRIENTINE HCL trientine HCl CAPSULE 250 mg Y N  
49884006001 TRIENTINE HCL trientine HCl CAPSULE 250 mg Y N  
72205000891 TRIENTINE HCL trientine HCl CAPSULE 250 mg Y N  
16571081205 TRIENTINE HCL trientine HCl CAPSULE 500 mg Y N  
73462010101 COSELA trilaciclib dihydrochloride VIAL 300 mg Y N  
57844021552 GALZIN zinc acetate CAPSULE 25 mg (zinc) Y N  
71863012425 GALZIN zinc acetate CAPSULE 25 mg (zinc) Y N  
57844037625 WILZIN zinc acetate CAPSULE 25 mg (zinc) Y N  
57844020852 GALZIN zinc acetate CAPSULE 50 mg (zinc) Y N  
71863012525 GALZIN zinc acetate CAPSULE 50 mg (zinc) Y N  
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