Antidiarrheals

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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
loperamide HCl LOPERAMIDE CAPSULE Y    
loperamide HCl ANTI-DIARRHEAL CAPSULE Y    
loperamide HCl LOPERAMIDE CAPSULE Y    
loperamide HCl IMODIUM A-D CAPSULE Y    
loperamide HCl ANTI-DIARRHEAL CAPSULE Y    
loperamide HCl LOPERAMIDE LIQUID Y    
loperamide HCl LOPERAMIDE HCL LIQUID Y    
loperamide HCl KENAMIDE LIQUID Y    
loperamide HCl LOPERAMIDE LIQUID Y    
loperamide HCl IMOGEN LIQUID Y    
loperamide HCl ANTI DIARRHEAL LIQUID Y    
loperamide HCl HM ANTI-DIARRHEAL LIQUID Y    
loperamide HCl ANTI-DIARRHEAL LIQUID Y    
loperamide HCl IMODIUM A-D LIQUID Y    
loperamide HCl ANTI-DIARRHEA TABLET Y    
loperamide HCl ANTI-DIARRHEAL TABLET Y    
loperamide HCl IMPERIM TABLET Y    
loperamide HCl KAO-PAVERIN TABLET Y    
loperamide HCl KAOPECTATE 1-D TABLET Y    
loperamide HCl IMOTIL TABLET Y    
loperamide HCl LO-PERAMIDE TABLET Y    
loperamide HCl HM ANTI-DIARRHEAL TABLET Y    
loperamide HCl LOPERAMIDE HCL TABLET Y    
loperamide HCl ULTRA A-D TABLET Y    
loperamide HCl LOPERAMIDE TABLET Y    
loperamide HCl IMODIUM A-D TABLET Y    
loperamide HCl DIAMODE TABLET Y    
loperamide HCl ANTI-DIARRHEAL TABLET Y    
loperamide HCl ANTIDIARRHEAL TABLET Y    
loperamide HCl ANTI-DIARRHEA TABLET Y    
loperamide HCl ANTI DIARRHEAL TABLET Y    
bismuth subsalicylate PINK BISMUTH ORAL SUSP N    
bismuth subsalicylate BISMUTH ORAL SUSP N    
bismuth subsalicylate KAO-TIN ORAL SUSP N    
bismuth subsalicylate STOMACH RELIEF ORAL SUSP N    
bismuth subsalicylate PEPTIC RELIEF ORAL SUSP N    
bismuth subsalicylate BISMATROL ORAL SUSP N    
bismuth subsalicylate BISMATROL TAB CHEW N    
bismuth subsalicylate BISMUTH TAB CHEW N    
bismuth subsalicylate PEPTIC RELIEF TAB CHEW N    
bismuth subsalicylate PINK BISMUTH TAB CHEW N    
bismuth subsalicylate STOMACH RELIEF TAB CHEW N    
bismuth subsalicylate BISMATROL TABLET N    
bismuth subsalicylate PINK BISMUTH TABLET N    
bismuth subsalicylate STOMACH RELIEF TABLET N    
crofelemer MYTESI TABLET DR N    
diphenoxylate HCl/atropine DIPHENOXYLATE-ATROPINE LIQUID N    
diphenoxylate HCl/atropine LOMOTIL TABLET N    
diphenoxylate HCl/atropine DIPHENOXYLATE-ATROPINE TABLET N    
opium tincture OPIUM TINCTURE TINCTURE N    
paregoric PAREGORIC LIQUID N    
telotristat etiprate XERMELO TABLET