Xanthine Derivatives

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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
00074490918 AMINOPHYLLINE aminophylline SYRINGE 250 mg/10 mL Y N  
00409592101 AMINOPHYLLINE aminophylline VIAL 250 mg/10 mL Y N  
00409592116 AMINOPHYLLINE aminophylline VIAL 250 mg/10 mL Y N  
00409592201 AMINOPHYLLINE aminophylline VIAL 500 mg/20 mL Y N  
00409592216 AMINOPHYLLINE aminophylline VIAL 500 mg/20 mL Y N  
46122045773 ALERT AID caffeine TABLET 200 mg Y N  
70000040901 CAFFEINE caffeine TABLET 200 mg Y N  
62011034001 STAY AWAKE caffeine TABLET 200 mg Y N  
70677112601 STAY AWAKE caffeine TABLET 200 mg Y N  
83324007416 STAY AWAKE caffeine TABLET 200 mg Y N  
25021060203 CAFFEINE CITRATE caffeine citrate SOLUTION 60 mg/3 mL (20 mg/mL) Y N  
47335029026 CAFFEINE CITRATE caffeine citrate SOLUTION 60 mg/3 mL (20 mg/mL) Y N  
47335029040 CAFFEINE CITRATE caffeine citrate SOLUTION 60 mg/3 mL (20 mg/mL) Y N  
47335029044 CAFFEINE CITRATE caffeine citrate SOLUTION 60 mg/3 mL (20 mg/mL) Y N  
51754050103 CAFFEINE CITRATE caffeine citrate SOLUTION 60 mg/3 mL (20 mg/mL) Y N  
63323040601 CAFFEINE CITRATE caffeine citrate SOLUTION 60 mg/3 mL (20 mg/mL) Y N  
63323040603 CAFFEINE CITRATE caffeine citrate SOLUTION 60 mg/3 mL (20 mg/mL) Y N  
72485011010 CAFFEINE CITRATE caffeine citrate SOLUTION 60 mg/3 mL (20 mg/mL) Y N  
00641616401 CAFCIT caffeine citrate VIAL 60 mg/3 mL (20 mg/mL) Y N  
00641616410 CAFCIT caffeine citrate VIAL 60 mg/3 mL (20 mg/mL) Y N  
00641626701 CAFFEINE CITRATE caffeine citrate VIAL 60 mg/3 mL (20 mg/mL) Y N  
00641626710 CAFFEINE CITRATE caffeine citrate VIAL 60 mg/3 mL (20 mg/mL) Y N  
25021060103 CAFFEINE CITRATE caffeine citrate VIAL 60 mg/3 mL (20 mg/mL) Y N  
47335028926 CAFFEINE CITRATE caffeine citrate VIAL 60 mg/3 mL (20 mg/mL) Y N  
51754050001 CAFFEINE CITRATE caffeine citrate VIAL 60 mg/3 mL (20 mg/mL) Y N  
63323040703 CAFFEINE CITRATE caffeine citrate VIAL 60 mg/3 mL (20 mg/mL) Y N  
63323040704 CAFFEINE CITRATE caffeine citrate VIAL 60 mg/3 mL (20 mg/mL) Y N  
72485010401 CAFFEINE CITRATE caffeine citrate VIAL 60 mg/3 mL (20 mg/mL) Y N  
72485010410 CAFFEINE CITRATE caffeine citrate VIAL 60 mg/3 mL (20 mg/mL) Y N  
00517250201 CAFFEINE AND SODIUM BENZOATE caffeine/sodium benzoate VIAL 250 mg/mL (125 mg/mL caffeine) Y N  
00517250210 CAFFEINE AND SODIUM BENZOATE caffeine/sodium benzoate VIAL 250 mg/mL (125 mg/mL caffeine) Y N  
00281111563 DILOR dyphylline TABLET 200 mg Y N  
00281111657 DILOR dyphylline TABLET 400 mg Y N  
00281111663 DILOR dyphylline TABLET 400 mg Y N  
00037073199 LUFYLLIN-400 dyphylline TABLET 400 mg Y N  
00430021424 CHOLEDYL SA oxtriphylline TABLET ER 400 mg Y N  
00430022124 CHOLEDYL SA oxtriphylline TABLET ER 600 mg Y N  
52244010010 THEO-24 theophylline anhydrous CAP ER 24H 100 mg Y N  
52244020010 THEO-24 theophylline anhydrous CAP ER 24H 200 mg Y N  
52244030010 THEO-24 theophylline anhydrous CAP ER 24H 300 mg Y N  
52244040010 THEO-24 theophylline anhydrous CAP ER 24H 400 mg Y N  
00121082016 THEOPHYLLINE theophylline anhydrous ELIXIR 80 mg/15 mL Y N  
00121482015 THEOPHYLLINE theophylline anhydrous ELIXIR 80 mg/15 mL (15 mL) Y N  
00121482040 THEOPHYLLINE theophylline anhydrous ELIXIR 80 mg/15 mL (15 mL) Y N  
00054384163 THEOPHYLLINE theophylline anhydrous SOLUTION 80 mg/15 mL Y N  
00054884504 THEOPHYLLINE theophylline anhydrous SOLUTION 80 mg/15 mL Y N  
00054884816 THEOPHYLLINE theophylline anhydrous SOLUTION 80 mg/15 mL Y N  
27808003301 THEOPHYLLINE theophylline anhydrous SOLUTION 80 mg/15 mL Y N  
62135055647 THEOPHYLLINE theophylline anhydrous SOLUTION 80 mg/15 mL Y N  
62135055624 THEOPHYLLINE theophylline anhydrous SOLUTION 80 mg/15 mL (15 mL) Y N  
62135055651 THEOPHYLLINE theophylline anhydrous SOLUTION 80 mg/15 mL (15 mL) Y N  
54092007005 QUIBRON-T/SR theophylline anhydrous TAB ER 12H 300 mg Y N  
00480331001 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
23155074101 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
31722007701 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
60219204501 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
62135045790 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
62332002531 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
64380024301 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
68462072101 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
69315022601 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
69452026720 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
70095001701 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
72578017301 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 300 mg Y N  
00480330901 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 450 mg Y N  
23155074201 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 450 mg Y N  
31722007801 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 450 mg Y N  
60219204601 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 450 mg Y N  
62332002631 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 450 mg Y N  
64380024401 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 450 mg Y N  
68462072201 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 450 mg Y N  
69315022701 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 450 mg Y N  
70095001801 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 450 mg Y N  
72578017401 THEOPHYLLINE ER theophylline anhydrous TAB ER 12H 450 mg Y N  
42858070101 THEOPHYLLINE ER theophylline anhydrous TAB ER 24H 400 mg Y N  
68462038001 THEOPHYLLINE ER theophylline anhydrous TAB ER 24H 400 mg Y N  
68462035601 THEOPHYLLINE ER theophylline anhydrous TAB ER 24H 600 mg Y N  
00409766823 THEOPHYLLINE IN 5% DEXTROSE theophylline in dextrose 5 % IV SOLN 200 mg/100 mL Y N  
00409767713 THEOPHYLLINE IN 5% DEXTROSE theophylline in dextrose 5 % IV SOLN 200 mg/50 mL Y N  
00264955820 THEOPHYLLINE IN 5% DEXTROSE theophylline in dextrose 5 % IV SOLN 400 mg/250 mL Y N  
00264555410 THEOPHYLLINE IN 5% DEXTROSE theophylline in dextrose 5 % IV SOLN 400 mg/500 mL Y N  
00409770562 THEOPHYLLINE IN 5% DEXTROSE theophylline in dextrose 5 % IV SOLN 800 mg/250 mL Y N  
00264555810 THEOPHYLLINE IN 5% DEXTROSE theophylline in dextrose 5 % IV SOLN 800 mg/500 mL Y N  
00264555400 THEOPHYLLINE IN 5% DEXTROSE theophylline in dextrose 5 % IV SOLN 800 mg/L Y N  
00264955400 THEOPHYLLINE IN 5% DEXTROSE theophylline in dextrose 5 % IV SOLN 800 mg/L Y N  
00338043904 THEOPHYLLINE IN 5% DEXTROSE theophylline in dextrose 5 % IV SOLN 800 mg/L Y N  
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