Tetracyclines, Oral

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Drug Use Review Documents

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 but eligible patients will encounter a co-pay at the pharmacy.
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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
doxycycline hyclate DOXYCYCLINE HYCLATE CAPSULE Y Quantity Limit  
doxycycline hyclate MORGIDOX CAPSULE Y Quantity Limit  
doxycycline hyclate VIBRAMYCIN CAPSULE Y Quantity Limit  
doxycycline hyclate DOXYCYCLINE HYCLATE TABLET Y Quantity Limit  
doxycycline monohydrate DOXYCYCLINE MONOHYDRATE CAPSULE Y Quantity Limit  
doxycycline monohydrate VIBRAMYCIN SUSP RECON Y Quantity Limit  
doxycycline monohydrate DOXYCYCLINE MONOHYDRATE SUSP RECON Y Quantity Limit  
tetracycline HCl TETRACYCLINE HCL CAPSULE Y Quantity Limit  
doxycycline calcium VIBRAMYCIN SYRUP N Quantity Limit  
doxycycline hyclate DOXYCYCLINE HYCLATE TABLET N Quantity Limit  
doxycycline hyclate DORYX MPC TABLET DR N Quantity Limit  
doxycycline hyclate DORYX TABLET DR N Quantity Limit  
doxycycline hyclate DOXYCYCLINE HYCLATE TABLET DR N Quantity Limit  
doxycycline monohydrate ORACEA CAP IR DR N Quantity Limit  
doxycycline monohydrate DOXYCYCLINE IR-DR CAP IR DR N Quantity Limit  
doxycycline monohydrate DOXYCYCLINE MONOHYDRATE CAPSULE N Quantity Limit  
doxycycline monohydrate DOXYCYCLINE MONOHYDRATE TABLET N Quantity Limit  
minocycline HCl XIMINO CAP ER 24H N Quantity Limit  
minocycline HCl MINOCYCLINE HCL CAPSULE N Quantity Limit  
minocycline HCl MINOCIN CAPSULE N Quantity Limit  
minocycline HCl SOLODYN TAB ER 24H N Quantity Limit  
minocycline HCl MINOCYCLINE HCL ER TAB ER 24H N Quantity Limit  
minocycline HCl MINOCYCLINE HCL TABLET N Quantity Limit  
demeclocycline HCl DEMECLOCYCLINE HCL TABLET Quantity Limit