Streptomycins

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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
AMIKACIN SULFATE AMIKACIN SULFATE VIAL    
GENTAMICIN IN NACL, ISO-OSM GENTAMICIN SULFATE IN NS PIGGYBACK    
GENTAMICIN SULFATE GENTAMICIN SULFATE VIAL    
GENTAMICIN SULFATE/PF GENTAMICIN SULFATE VIAL    
NEOMYCIN SULFATE NEOMYCIN SULFATE TABLET    
STREPTOMYCIN SULFATE STREPTOMYCIN SULFATE VIAL    
TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE VIAL    
VANCOMYCIN HCL VANCOMYCIN HCL VIAL PORT    
VANCOMYCIN HCL IN DEXTROSE 5 % VANCOMYCIN HCL-D5W FROZ.PIGGY    
VANCOMYCIN HCL IN DEXTROSE 5 % VANCOMYCIN HCL FROZ.PIGGY    
VANCOMYCIN HCL IN DEXTROSE 5 % VANCOMYCIN FROZ.PIGGY    
VANCOMYCIN/0.9 % SOD CHLORIDE VANCOMYCIN HCL-0.9% NACL FROZ.PIGGY