Potassium and K-Phos, 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
POT CHLORIDE/CAL PHOS/MAG MEDI-LYTE TABLET Y    
POTASSIUM POTASSIUM TABLET Y    
POTASSIUM NATURAL POTASSIUM TABLET Y    
POTASSIUM BICARBONATE/CIT AC K EFFERVESCENT TABLET EFF Y    
POTASSIUM BICARBONATE/CIT AC KLOR-CON-EF TABLET EFF Y    
POTASSIUM BICARBONATE/CIT AC POTASSIUM BICARBONATE TABLET EFF Y    
POTASSIUM BICARBONATE/CIT AC EFFER-K TABLET EFF Y 10 mEq, 20 mEq Require PA  
POTASSIUM CHLORIDE KLOR-CON M15 TAB ER PRT Y    
POTASSIUM CHLORIDE KLOR-CON M10 TAB ER PRT Y    
POTASSIUM CHLORIDE KLOR-CON M20 TAB ER PRT Y    
POTASSIUM CHLORIDE POTASSIUM CHLORIDE TAB ER PRT Y    
POTASSIUM CHLORIDE KLOR-CON 8 TABLET ER Y    
POTASSIUM CHLORIDE KLOR-CON 10 TABLET ER Y    
POTASSIUM CHLORIDE K-TAB ER TABLET ER Y    
POTASSIUM CHLORIDE POTASSIUM CHLORIDE TABLET ER Y    
POTASSIUM PHOSPHATE,MONOBASIC K-PHOS ORIGINAL TABLET SOL Y    
SOD PHOS DI, MONO/K PHOS MONO VIRT-PHOS 250 NEUTRAL TABLET Y    
SOD PHOS DI, MONO/K PHOS MONO K-PHOS NEUTRAL TABLET Y    
SOD PHOS DI, MONO/K PHOS MONO PHOSPHA 250 NEUTRAL TABLET Y    
SOD PHOS DI, MONO/K PHOS MONO PHOSPHO-TRIN 250 NEUTRAL TABLET Y    
SOD PHOS,M-B/K PHOS,MONOB K-PHOS NO.2 TABLET Y    
SODIUM,POTASSIUM PHOSPHATES PHOS-NAK POWD PACK Y    
POT CHLORIDE/POT BICARB/CIT AC POTASSIUM CHLORIDE TABLET EFF N    
POTASSIUM CHLORIDE KLOR-CON SPRINKLE CAPSULE ER N    
POTASSIUM CHLORIDE POTASSIUM CHLORIDE CAPSULE ER N    
POTASSIUM CHLORIDE POTASSIUM CHLORIDE LIQUID N    
POTASSIUM CHLORIDE KLOR-CON PACKET N    
POTASSIUM CHLORIDE POTASSIUM CHLORIDE PACKET N