Parasympathetic Agents

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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
00832051100 BETHANECHOL CHLORIDE bethanechol chloride TABLET 10 mg Y N  
00832051101 BETHANECHOL CHLORIDE bethanechol chloride TABLET 10 mg Y N  
00832051189 BETHANECHOL CHLORIDE bethanechol chloride TABLET 10 mg Y N  
23155093501 BETHANECHOL CHLORIDE bethanechol chloride TABLET 10 mg Y N  
53746057201 BETHANECHOL CHLORIDE bethanechol chloride TABLET 10 mg Y N  
60687068901 BETHANECHOL CHLORIDE bethanechol chloride TABLET 10 mg Y N  
60687068911 BETHANECHOL CHLORIDE bethanechol chloride TABLET 10 mg Y N  
62135075612 BETHANECHOL CHLORIDE bethanechol chloride TABLET 10 mg Y N  
65162057210 BETHANECHOL CHLORIDE bethanechol chloride TABLET 10 mg Y N  
00832051200 BETHANECHOL CHLORIDE bethanechol chloride TABLET 25 mg Y N  
00832051201 BETHANECHOL CHLORIDE bethanechol chloride TABLET 25 mg Y N  
00832051289 BETHANECHOL CHLORIDE bethanechol chloride TABLET 25 mg Y N  
23155093601 BETHANECHOL CHLORIDE bethanechol chloride TABLET 25 mg Y N  
53746057301 BETHANECHOL CHLORIDE bethanechol chloride TABLET 25 mg Y N  
60687070001 BETHANECHOL CHLORIDE bethanechol chloride TABLET 25 mg Y N  
60687070011 BETHANECHOL CHLORIDE bethanechol chloride TABLET 25 mg Y N  
62135075712 BETHANECHOL CHLORIDE bethanechol chloride TABLET 25 mg Y N  
65162057310 BETHANECHOL CHLORIDE bethanechol chloride TABLET 25 mg Y N  
00527133201 BETHANECHOL CHLORIDE bethanechol chloride TABLET 5 mg Y N  
00832051000 BETHANECHOL CHLORIDE bethanechol chloride TABLET 5 mg Y N  
23155093401 BETHANECHOL CHLORIDE bethanechol chloride TABLET 5 mg Y N  
53746057101 BETHANECHOL CHLORIDE bethanechol chloride TABLET 5 mg Y N  
62135075590 BETHANECHOL CHLORIDE bethanechol chloride TABLET 5 mg Y N  
65162057110 BETHANECHOL CHLORIDE bethanechol chloride TABLET 5 mg Y N  
00832051300 BETHANECHOL CHLORIDE bethanechol chloride TABLET 50 mg Y N  
00832051301 BETHANECHOL CHLORIDE bethanechol chloride TABLET 50 mg Y N  
00832051389 BETHANECHOL CHLORIDE bethanechol chloride TABLET 50 mg Y N  
23155093701 BETHANECHOL CHLORIDE bethanechol chloride TABLET 50 mg Y N  
53746057401 BETHANECHOL CHLORIDE bethanechol chloride TABLET 50 mg Y N  
62135075812 BETHANECHOL CHLORIDE bethanechol chloride TABLET 50 mg Y N  
65162057410 BETHANECHOL CHLORIDE bethanechol chloride TABLET 50 mg Y N  
00054033425 CEVIMELINE HCL cevimeline HCl CAPSULE 30 mg Y N  
00713093701 CEVIMELINE HCL cevimeline HCl CAPSULE 30 mg Y N  
16571065710 CEVIMELINE HCL cevimeline HCl CAPSULE 30 mg Y N  
43386099901 CEVIMELINE HCL cevimeline HCl CAPSULE 30 mg Y N  
59651042201 CEVIMELINE HCL cevimeline HCl CAPSULE 30 mg Y N  
63304047901 CEVIMELINE HCL cevimeline HCl CAPSULE 30 mg Y N  
69452031620 CEVIMELINE HCL cevimeline HCl CAPSULE 30 mg Y N  
72888011801 CEVIMELINE HCL cevimeline HCl CAPSULE 30 mg Y N  
72888011830 CEVIMELINE HCL cevimeline HCl CAPSULE 30 mg Y N  
00713088301 EVOXAC cevimeline HCl CAPSULE 30 mg Y N  
42023026901 PREVDUO glycopyrrolate/neostigmine SYRINGE 0.6 mg-3 mg/3 mL (0.2 mg-1 mg/mL) Y N  
42023026905 PREVDUO glycopyrrolate/neostigmine SYRINGE 0.6 mg-3 mg/3 mL (0.2 mg-1 mg/mL) Y N  
00641624001 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate SYRINGE 3 mg/3 mL (1 mg/mL) Y N  
00641624010 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate SYRINGE 3 mg/3 mL (1 mg/mL) Y N  
43598094511 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate SYRINGE 3 mg/3 mL (1 mg/mL) Y N  
43598094558 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate SYRINGE 3 mg/3 mL (1 mg/mL) Y N  
76045021400 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate SYRINGE 3 mg/3 mL (1 mg/mL) Y N  
76045021430 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate SYRINGE 3 mg/3 mL (1 mg/mL) Y N  
76045038313 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate SYRINGE 3 mg/3 mL (1 mg/mL) Y N  
76045038330 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate SYRINGE 3 mg/3 mL (1 mg/mL) Y N  
51754120001 BLOXIVERZ neostigmine methylsulfate SYRINGE 5 mg/5 mL (1 mg/mL) Y N  
51754120003 BLOXIVERZ neostigmine methylsulfate SYRINGE 5 mg/5 mL (1 mg/mL) Y N  
00548960100 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
00641615001 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
00641615010 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
00641626401 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
00641626410 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
23155051731 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
23155051741 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
25021061010 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
42023018801 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
42023018810 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
43598052811 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
43598052836 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
63323041310 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
70069080501 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
70069080510 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
70700017122 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
70700017123 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
71288050010 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
71288050011 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
71839010501 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
72572046001 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
72572046024 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 0.5 mg/mL Y N  
51754122001 BLOXIVERZ neostigmine methylsulfate VIAL 1 mg/mL Y N  
51754122003 BLOXIVERZ neostigmine methylsulfate VIAL 1 mg/mL Y N  
00548960200 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
00641614901 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
00641614910 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
00641626501 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
00641626510 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
00641627701 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
00641627710 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
00703270403 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
23155051831 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
23155051841 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
25021061110 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
31722099510 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
31722099531 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
42023018901 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
42023018910 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
43598052911 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
43598052936 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
63323041501 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
63323041510 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
63323041536 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
65219081101 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
65219081110 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
70069080601 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
70069080610 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
70700017222 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
70700017223 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
71288050110 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
71288050111 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
71839010601 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
71839010610 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
72572046101 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
72572046124 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
72572046201 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
72572046210 NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate VIAL 1 mg/mL Y N  
81284083105 ANTICHOLIUM physostigmine salicylate AMPUL 0.4 mg/mL Y N  
00115592201 PILOCARPINE HCL pilocarpine HCl TABLET 5 mg Y N  
00228280111 PILOCARPINE HCL pilocarpine HCl TABLET 5 mg Y N  
00527131301 PILOCARPINE HCL pilocarpine HCl TABLET 5 mg Y N  
00574079201 PILOCARPINE HCL pilocarpine HCl TABLET 5 mg Y N  
50268065211 PILOCARPINE HCL pilocarpine HCl TABLET 5 mg Y N  
50268065212 PILOCARPINE HCL pilocarpine HCl TABLET 5 mg Y N  
59651022401 PILOCARPINE HCL pilocarpine HCl TABLET 5 mg Y N  
60219592201 PILOCARPINE HCL pilocarpine HCl TABLET 5 mg Y N  
68084092825 PILOCARPINE HCL pilocarpine HCl TABLET 5 mg Y N  
68084092895 PILOCARPINE HCL pilocarpine HCl TABLET 5 mg Y N  
69292026501 PILOCARPINE HCL pilocarpine HCl TABLET 5 mg Y N  
00228283711 PILOCARPINE HCL pilocarpine HCl TABLET 7.5 mg Y N  
00527140701 PILOCARPINE HCL pilocarpine HCl TABLET 7.5 mg Y N  
59651022501 PILOCARPINE HCL pilocarpine HCl TABLET 7.5 mg Y N  
00781304072 REGONOL pyridostigmine bromide AMPUL 5 mg/mL Y N  
00781304095 REGONOL pyridostigmine bromide AMPUL 5 mg/mL Y N  
16571083316 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide SOLUTION 60 mg/5 mL Y N  
42192062616 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide SOLUTION 60 mg/5 mL Y N  
66689040601 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide SOLUTION 60 mg/5 mL Y N  
66689040610 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide SOLUTION 60 mg/5 mL Y N  
69238173102 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide SOLUTION 60 mg/5 mL Y N  
70954014810 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide SOLUTION 60 mg/5 mL Y N  
72205009872 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide SOLUTION 60 mg/5 mL Y N  
58657081010 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide TABLET 30 mg Y N  
58657081021 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide TABLET 30 mg Y N  
00115351101 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide TABLET 60 mg Y N  
00904662261 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide TABLET 60 mg Y N  
62559047001 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide TABLET 60 mg Y N  
68084049401 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide TABLET 60 mg Y N  
68084049411 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide TABLET 60 mg Y N  
68382065906 PYRIDOSTIGMINE BROMIDE pyridostigmine bromide TABLET 60 mg Y N  
60846055910 PYRIDOSTIGMINE BROMIDE ER pyridostigmine bromide TABLET ER 105 mg Y N  
60846055927 PYRIDOSTIGMINE BROMIDE ER pyridostigmine bromide TABLET ER 105 mg Y N  
00115140408 PYRIDOSTIGMINE BROMIDE ER pyridostigmine bromide TABLET ER 180 mg Y N  
47781033530 PYRIDOSTIGMINE BROMIDE ER pyridostigmine bromide TABLET ER 180 mg Y N  
64980022003 PYRIDOSTIGMINE BROMIDE ER pyridostigmine bromide TABLET ER 180 mg Y N  
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