Misc Antibiotics
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.
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 |
|---|---|---|---|---|---|
| aztreonam | AZACTAM | VIAL | |||
| aztreonam | AZTREONAM | VIAL | |||
| bacitracin | BACI-IM | VIAL | |||
| bacitracin | BACITRACIN | VIAL | |||
| ciprofloxacin in 5 % dextrose | CIPROFLOXACIN-D5W | PIGGYBACK | |||
| ciprofloxacin lactate | CIPRO I.V. | VIAL | |||
| clindamycin HCl | CLINDAMYCIN HCL | CAPSULE | |||
| clindamycin HCl | CLEOCIN HCL | CAPSULE | |||
| clindamycin in 0.9 % sod chlor | CLINDAMYCIN-0.9% NACL | PIGGYBACK | |||
| clindamycin palmitate HCl | CLEOCIN PEDIATRIC | SOLN RECON | |||
| clindamycin palmitate HCl | CLINDAMYCIN (PEDIATRIC) | SOLN RECON | |||
| clindamycin phosphate | CLEOCIN PHOSPHATE | VIAL | |||
| clindamycin phosphate | CLINDAMYCIN PHOSPHATE | VIAL | |||
| clindamycin phosphate/D5W | CLINDAMYCIN PHOSPHATE-D5W | PIGGYBACK | |||
| colistin (colistimethate Na) | COLISTIMETHATE | VIAL | |||
| colistin (colistimethate Na) | COLY-MYCIN M PARENTERAL | VIAL | |||
| dalbavancin HCl | DALVANCE | VIAL | |||
| daptomycin | CUBICIN RF | VIAL | |||
| daptomycin | DAPTOMYCIN | VIAL | |||
| daptomycin in 0.9 % sod chlor | DAPTOMYCIN-0.9% NACL | FROZ.PIGGY | |||
| delafloxacin meglumine | BAXDELA | VIAL | |||
| ertapenem sodium | ERTAPENEM | VIAL | |||
| imipenem/cilastatin sodium | IMIPENEM-CILASTATIN SODIUM | VIAL | |||
| imipenem/cilastatin sodium | PRIMAXIN | VIAL | |||
| imipenem/cilastatin/relebactam | RECARBRIO | VIAL | |||
| lincomycin HCl | LINCOJECT | VIAL | |||
| lincomycin HCl | LINCOCIN | VIAL | |||
| lincomycin HCl | LINCOMYCIN HCL | VIAL | |||
| linezolid in 0.9% sodium chlor | LINEZOLID-0.9% NACL | PIGGYBACK | |||
| linezolid in dextrose 5% | LINEZOLID-D5W | PIGGYBACK | |||
| linezolid in dextrose 5% | ZYVOX | PIGGYBACK | |||
| meropenem | MERREM | INFUS. BTL | |||
| meropenem | MEROPENEM | VIAL | |||
| meropenem | MERREM | VIAL PORT | |||
| meropenem-0.9% sodium chloride | MEROPENEM-0.9% NACL | PIGGYBACK | |||
| meropenem/vaborbactam | VABOMERE | VIAL | |||
| moxifloxacin-sod.chloride(iso) | MOXIFLOXACIN | PIGGYBACK | |||
| moxifloxacin/sod.ace,sul/water | MOXIFLOXACIN | PIGGYBACK | |||
| oritavancin diphosphate | ORBACTIV | VIAL | |||
| oritavancin diphosphate | KIMYRSA | VIAL | |||
| polymyxin B sulfate | POLYMYXIN B SULFATE | VIAL | |||
| tedizolid phosphate | SIVEXTRO | VIAL | |||
| telavancin HCl | VIBATIV | VIAL | |||
| thalidomide | THALOMID | CAPSULE | |||
| tigecycline | TYGACIL | VIAL | |||
| tigecycline | TIGECYCLINE | VIAL |