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 VIBRAMYCIN CAPSULE Y    
DOXYCYCLINE HYCLATE MORGIDOX CAPSULE Y    
DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE CAPSULE Y    
DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE TABLET Y 150 mg, 75 mg Require PA  
DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE CAPSULE Y 150 mg, 75 mg Require PA  
DOXYCYCLINE MONOHYDRATE VIBRAMYCIN SUSP RECON Y    
DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE SUSP RECON Y    
TETRACYCLINE HCL TETRACYCLINE HCL CAPSULE Y    
DOXYCYCLINE CALCIUM VIBRAMYCIN SYRUP N    
DOXYCYCLINE HYCLATE DORYX TABLET DR N    
DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE TABLET DR N    
DOXYCYCLINE HYCLATE DORYX MPC TABLET DR N    
DOXYCYCLINE MONOHYDRATE ORACEA CAP IR DR N    
DOXYCYCLINE MONOHYDRATE DOXYCYCLINE IR-DR CAP IR DR N    
DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE TABLET N    
MINOCYCLINE HCL MINOCYCLINE HCL CAPSULE N    
MINOCYCLINE HCL MINOCYCLINE HCL ER TAB ER 24H N    
MINOCYCLINE HCL SOLODYN TAB ER 24H N    
MINOCYCLINE HCL MINOCYCLINE HCL TABLET N    
DEMECLOCYCLINE HCL DEMECLOCYCLINE HCL TABLET