Antiemetics, Conventional

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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
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL SOLUTION Y    
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL TABLET Y    
METOCLOPRAMIDE HCL REGLAN TABLET Y    
PHOSPHORATED CARBO(DEXT-FRUCT) ANTI-NAUSEA SOLUTION Y    
PHOSPHORATED CARBO(DEXT-FRUCT) FORMULA EM SOLUTION Y    
PHOSPHORATED CARBO(DEXT-FRUCT) NAUSEA RELIEF SOLUTION Y    
PHOSPHORATED CARBO(DEXT-FRUCT) NAUSEA CONTROL SOLUTION Y    
PHOSPHORATED CARBO(DEXT-FRUCT) NAUSEA RELIEF SOLUTION Y    
PHOSPHORATED CARBO(DEXT-FRUCT) EMETROL SOLUTION Y    
PHOSPHORATED CARBO(DEXT-FRUCT) ANTI-NAUSEA SOLUTION Y    
PHOSPHORATED CARBO(DEXT-FRUCT) ESPECOL SOLUTION Y    
PROCHLORPERAZINE PROCHLORPERAZINE SUPP.RECT Y    
PROCHLORPERAZINE COMPRO SUPP.RECT Y    
PROCHLORPERAZINE MALEATE PROCHLORPERAZINE MALEATE TABLET Y    
PROMETHAZINE HCL PHENERGAN SUPP.RECT Y    
PROMETHAZINE HCL PROMETHEGAN SUPP.RECT Y    
PROMETHAZINE HCL PROMETHAZINE HCL SUPP.RECT Y    
PROMETHAZINE HCL PHENADOZ SUPP.RECT Y    
PROMETHAZINE HCL PROMETHAZINE HCL SYRUP Y    
PROMETHAZINE HCL PROMETHAZINE HCL TABLET Y    
DIMENHYDRINATE TRAVEL SICKNESS TABLET N PA Document  
DIMENHYDRINATE MOTION SICKNESS RELIEF TABLET N PA Document  
DIMENHYDRINATE MOTION SICKNESS TABLET N PA Document  
DIMENHYDRINATE DRIMINATE TABLET N PA Document  
DRONABINOL MARINOL CAPSULE N Quantity Limit  
DRONABINOL DRONABINOL CAPSULE N Quantity Limit  
MECLIZINE HCL TRAVEL SICKNESS TAB CHEW N PA Document  
MECLIZINE HCL MOTION-TIME TAB CHEW N PA Document  
MECLIZINE HCL MECLIZINE HCL TAB CHEW N PA Document  
MECLIZINE HCL MECLIZINE HCL TABLET N PA Document  
MECLIZINE HCL MOTION RELIEF TABLET N PA Document  
MECLIZINE HCL MOTION SICKNESS TABLET N PA Document  
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL ODT TAB RAPDIS N PA Document  
NABILONE CESAMET CAPSULE N PA Document  
SCOPOLAMINE TRANSDERM-SCOP PATCH TD 3 N PA Document  
TRIMETHOBENZAMIDE HCL TIGAN CAPSULE N PA Document  
TRIMETHOBENZAMIDE HCL TRIMETHOBENZAMIDE HCL CAPSULE N PA Document  
DIMENHYDRINATE DIMENHYDRINATE VIAL    
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL SYRINGE    
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL VIAL    
PROCHLORPERAZINE EDISYLATE PROCHLORPERAZINE EDISYLATE VIAL    
PROMETHAZINE HCL PHENERGAN AMPUL    
PROMETHAZINE HCL PROMETHAZINE HCL AMPUL    
PROMETHAZINE HCL PROMETHAZINE HCL VIAL    
PROMETHAZINE HCL PHENERGAN VIAL    
TRIMETHOBENZAMIDE HCL TIGAN VIAL