Tetracyclines, Oral
PDL Reference Documents
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.
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 | VIBRAMYCIN | CAPSULE | Y | Quantity Limit | |
| doxycycline hyclate | MORGIDOX | CAPSULE | Y | Quantity Limit | |
| doxycycline hyclate | ED DOXY-CAPS | CAPSULE | Y | Quantity Limit | |
| doxycycline hyclate | LYMEPAK | TABLET | Y | Quantity Limit | |
| doxycycline hyclate | DOXYCYCLINE HYCLATE | TABLET | Y | Quantity Limit | |
| doxycycline monohydrate | DOXYCYCLINE MONOHYDRATE | CAPSULE | Y | Quantity Limit | |
| doxycycline monohydrate | DOXYCYCLINE MONOHYDRATE | SUSP RECON | Y | Quantity Limit | |
| tetracycline HCl | TETRACYCLINE HCL | CAPSULE | Y | Quantity Limit | |
| doxycycline hyclate | DOXYCYCLINE HYCLATE | TABLET | N | Quantity Limit | |
| doxycycline hyclate | DORYX | TABLET DR | N | Quantity Limit | |
| doxycycline hyclate | DORYX MPC | TABLET DR | N | Quantity Limit | |
| doxycycline hyclate | DOXYCYCLINE HYCLATE | TABLET 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 | |
| doxycycline monohydrate | ADOXA | TABLET | N | Quantity Limit | |
| doxycycline monohydrate | ADOXA PAK | TABLET | N | Quantity Limit | |
| minocycline HCl | MINOCYCLINE HCL | CAPSULE | N | Quantity Limit | |
| minocycline HCl | DYNACIN | CAPSULE | N | Quantity Limit | |
| minocycline HCl | MINOLIRA ER | TAB BP 24H | 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 | |
| omadacycline tosylate | NUZYRA | TABLET | N | Quantity Limit | |
| demeclocycline HCl | DEMECLOCYCLINE HCL | TABLET | Quantity Limit | ||
| doxycycline monohydrate | DOXYCYCLINE MONOHYDRATE | SUSP RECON | Quantity Limit |