Macrolides, Oral

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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 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
AZITHROMYCIN ZITHROMAX SUSP RECON Y    
AZITHROMYCIN AZITHROMYCIN SUSP RECON Y    
AZITHROMYCIN ZITHROMAX TRI-PAK TABLET Y    
AZITHROMYCIN ZITHROMAX TABLET Y    
AZITHROMYCIN AZITHROMYCIN TABLET Y    
CLARITHROMYCIN CLARITHROMYCIN TABLET Y    
AZITHROMYCIN ZITHROMAX PACKET N    
AZITHROMYCIN AZITHROMYCIN PACKET N    
AZITHROMYCIN ZMAX SUS ER REC N    
CLARITHROMYCIN CLARITHROMYCIN SUSP RECON N    
CLARITHROMYCIN CLARITHROMYCIN ER TAB ER 24H N    
ERYTHROMYCIN BASE ERYTHROMYCIN CAPSULE DR N    
ERYTHROMYCIN BASE PCE TAB PART N    
ERYTHROMYCIN BASE ERYTHROMYCIN TABLET N    
ERYTHROMYCIN BASE ERY-TAB TABLET DR N    
ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 200 SUSP RECON N    
ERYTHROMYCIN ETHYLSUCCINATE ERYPED 200 SUSP RECON N    
ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE SUSP RECON N    
ERYTHROMYCIN ETHYLSUCCINATE ERYPED 400 SUSP RECON N    
ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 400 TABLET N    
ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE TABLET N    
ERYTHROMYCIN STEARATE ERYTHROCIN STEARATE TABLET N