Urinary Antibacterials, Analgesics

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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
Current Drug Use Criteria New Drug Evaluation
levofloxacin LEVOFLOXACIN VIAL    
levofloxacin in dextrose 5 % LEVOFLOXACIN-D5W PIGGYBACK    
meth/meblue/sod phos/psal/hyos URIN D.S. TABLET    
meth/meblue/sod phos/psal/hyos URELLE TABLET    
methen/mblue/sal/sod phos/hyos URIMAR-T TABLET    
methenam/sod phos/mblue/hyoscy UROLET MB TABLET    
methenam/sod phos/mblue/hyoscy UROGESIC-BLUE TABLET    
methenamine hippurate METHENAMINE HIPPURATE TABLET    
methenamine hippurate HIPREX TABLET    
methenamine mandelate METHENAMINE MANDELATE TABLET    
nitrofurantoin macrocrystal NITROFURANTOIN CAPSULE    
nitrofurantoin macrocrystal MACRODANTIN CAPSULE    
nitrofurantoin monohyd/m-cryst MACROBID CAPSULE    
nitrofurantoin monohyd/m-cryst NITROFURANTOIN MONO-MACRO CAPSULE