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 NATURAL POTASSIUM TABLET Y    
potassium POTASSIUM-99 TABLET Y    
potassium POTASSIUM TABLET Y    
potassium bicarbonate/cit ac EFFER-K TABLET EFF Y 10 mEq, 20 mEq Require PA  
potassium bicarbonate/cit ac POTASSIUM BICARBONATE TABLET EFF Y    
potassium bicarbonate/cit ac KLOR-CON-EF TABLET EFF Y    
potassium bicarbonate/cit ac K EFFERVESCENT TABLET EFF Y    
potassium chloride KLOR-CON M20 TAB ER PRT Y    
potassium chloride POTASSIUM CHLORIDE TAB ER PRT Y    
potassium chloride KLOR-CON M15 TAB ER PRT Y    
potassium chloride KLOR-CON M10 TAB ER PRT Y    
potassium chloride K-TAB ER TABLET ER Y    
potassium chloride POTASSIUM CHLORIDE TABLET ER Y    
potassium chloride KLOR-CON 10 TABLET ER Y    
potassium chloride KLOR-CON 8 TABLET ER Y    
potassium phosphate,monobasic K-PHOS ORIGINAL TABLET SOL 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 VIRT-PHOS 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 EPIKLOR PACKET N    
potassium chloride POTASSIUM CHLORIDE PACKET N    
potassium chloride KLOR-CON PACKET N