Streptomycins

← Back to Class List

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    
kanamycin sulfate KANAMYCIN 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 5 % dextrose VANCOMYCIN HCL FROZ.PIGGY    
vancomycin HCl in 5 % dextrose VANCOMYCIN HCL-D5W FROZ.PIGGY    
vancomycin HCl in 5 % dextrose VANCOMYCIN FROZ.PIGGY    
vancomycin/0.9 % sod chloride VANCOMYCIN HCL-0.9% NACL FROZ.PIGGY