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 ANTI-DIARRHEAL CAPSULE Y    
LOPERAMIDE HCL LOPERAMIDE CAPSULE Y    
LOPERAMIDE HCL ANTI-DIARRHEAL CAPSULE Y    
LOPERAMIDE HCL IMODIUM A-D CAPSULE Y    
LOPERAMIDE HCL LOPERAMIDE CAPSULE Y    
LOPERAMIDE HCL LOPERAMIDE LIQUID Y    
LOPERAMIDE HCL IMODIUM A-D LIQUID Y    
LOPERAMIDE HCL LOPERAMIDE HCL LIQUID Y    
LOPERAMIDE HCL LOPERAMIDE LIQUID Y    
LOPERAMIDE HCL ANTI-DIARRHEAL LIQUID Y    
LOPERAMIDE HCL ANTI-DIARRHEA TABLET Y    
LOPERAMIDE HCL ANTI-DIARRHEAL TABLET Y    
LOPERAMIDE HCL ULTRA A-D TABLET Y    
LOPERAMIDE HCL LOPERAMIDE HCL 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    
BISMUTH SUBSALICYLATE BISMUTH ORAL SUSP N    
BISMUTH SUBSALICYLATE KAO-TIN ORAL SUSP N    
BISMUTH SUBSALICYLATE PEPTIC RELIEF ORAL SUSP N    
BISMUTH SUBSALICYLATE PINK BISMUTH ORAL SUSP N    
BISMUTH SUBSALICYLATE STOMACH RELIEF ORAL SUSP N    
BISMUTH SUBSALICYLATE BISMATROL ORAL SUSP N    
BISMUTH SUBSALICYLATE PEPTIC RELIEF TAB CHEW N    
BISMUTH SUBSALICYLATE PINK BISMUTH TAB CHEW N    
BISMUTH SUBSALICYLATE BISMATROL TAB CHEW N    
BISMUTH SUBSALICYLATE STOMACH RELIEF TAB CHEW N    
BISMUTH SUBSALICYLATE STOMACH RELIEF TABLET N    
BISMUTH SUBSALICYLATE PINK BISMUTH TABLET N    
CROFELEMER MYTESI TABLET DR N    
DIPHENOXYLATE HCL/ATROPINE DIPHENOXYLATE-ATROPINE LIQUID N    
DIPHENOXYLATE HCL/ATROPINE DIPHENOXYLATE-ATROPINE TABLET N    
DIPHENOXYLATE HCL/ATROPINE LOMOTIL TABLET N    
OPIUM TINCTURE OPIUM TINCTURE TINCTURE N    
PAREGORIC PAREGORIC LIQUID N