Protein Lysates
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 |
|---|---|---|---|---|---|---|---|---|
| 00338045703 | TRAVASOL W/ELECTROLYTES | AA 5.5 %/electrolyte-TPN soln | IV SOLN | 5.5 % | Y | N | ||
| 00338045704 | TRAVASOL W/ELECTROLYTES | AA 5.5 %/electrolyte-TPN soln | IV SOLN | 5.5 % | Y | N | ||
| 00338045706 | TRAVASOL W/ELECTROLYTES | AA 5.5 %/electrolyte-TPN soln | IV SOLN | 5.5 % | Y | N | ||
| 00338063198 | TRAVASOL WITH ELECTROLYTES | AA 5.5 %/electrolyte-TPN soln | IV SOLN | 5.5 % | Y | N | ||
| 00904318146 | AMINO ACID MEGA | amino acids | TABLET | Y | N | Pharmacy PA | ||
| 00904318152 | AMINO ACID MEGA | amino acids | TABLET | Y | N | Pharmacy PA | ||
| 00338064998 | TRAVASOL | amino acids 5.5 % | IV SOLN | 5.5 % (5.5 gram/100 mL) | Y | N | ||
| 00338082104 | TRAVASOL W/DEXTROSE | amino acids 5.5 %/dextrose 10% | IV SOLN | 5.5 % | Y | N | ||
| 00074299601 | AMINOSYN | amino acids 7 %/dextrose 50 % | KIT | 7 %-50 % | Y | N | ||
| 00904421551 | ARGININE | arginine | TABLET | 500 mg | Y | N | Pharmacy PA | |
| 00409897510 | L-CYSTEINE | cysteine HCl | SYRINGE | 50 mg/mL | Y | N | ||
| 00264600003 | CYSTEINE HYDROCHLORIDE | cysteine HCl | VIAL | 50 mg/mL | Y | N | ||
| 51754100701 | ELCYS | cysteine HCl | VIAL | 50 mg/mL | Y | N | ||
| 51754100703 | ELCYS | cysteine HCl | VIAL | 50 mg/mL | Y | N | ||
| 50268051911 | LYSINE | lysine | TABLET | 500 mg | Y | N | Pharmacy PA | |
| 50268051915 | LYSINE | lysine | TABLET | 500 mg | Y | N | Pharmacy PA |