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
Status
Current Drug Use Criteria New Drug Evaluation
LEVOFLOXACIN LEVOFLOXACIN VIAL    
LEVOFLOXACIN/D5W 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 UROGESIC-BLUE TABLET    
METHENAMINE HIPPURATE METHENAMINE HIPPURATE TABLET    
METHENAMINE HIPPURATE HIPREX TABLET    
METHENAMINE MANDELATE METHENAMINE MANDELATE TABLET    
NITROFURANTOIN NITROFURANTOIN ORAL SUSP    
NITROFURANTOIN MACROCRYSTAL MACRODANTIN CAPSULE    
NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN CAPSULE    
NITROFURANTOIN MONOHYD/M-CRYST NITROFURANTOIN MONO-MACRO CAPSULE    
NITROFURANTOIN MONOHYD/M-CRYST MACROBID CAPSULE