Antifungals, Parenteral

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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
isavuconazonium sulfate CRESEMBA VIAL N    
amphotericin B AMPHOTERICIN B VIAL    
amphotericin B lipid complex ABELCET VIAL    
amphotericin B liposome AMBISOME VIAL    
anidulafungin ERAXIS (WATER DILUENT) VIAL    
caspofungin acetate CANCIDAS VIAL    
caspofungin acetate CASPOFUNGIN ACETATE VIAL    
fluconazole in dextrose,iso-os FLUCONAZOLE IN DEXTROSE PIGGYBACK    
fluconazole in NaCL,iso-osm FLUCONAZOLE IN SALINE PGGYBK BTL    
fluconazole in NaCL,iso-osm FLUCONAZOLE IN SALINE PIGGYBACK    
fluconazole in NaCL,iso-osm FLUCONAZOLE-NACL PIGGYBACK    
micafungin sodium MYCAMINE VIAL    
posaconazole NOXAFIL VIAL    
voriconazole VFEND IV VIAL    
voriconazole VORICONAZOLE VIAL