← 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
Current Drug Use Criteria New Drug Evaluation
albendazole ALBENZA TABLET    
atovaquone MEPRON ORAL SUSP    
dapsone DAPSONE TABLET    
ivermectin STROMECTOL TABLET    
ivermectin IVERMECTIN TABLET    
mebendazole EMVERM TAB CHEW    
metronidazole/sodium chloride METRO IV PIGGYBACK    
metronidazole/sodium chloride METRONIDAZOLE PIGGYBACK    
miltefosine IMPAVIDO CAPSULE    
nitazoxanide ALINIA SUSP RECON    
nitazoxanide ALINIA TABLET    
paromomycin sulfate PAROMOMYCIN SULFATE CAPSULE    
pentamidine isethionate PENTAM 300 VIAL    
pentamidine isethionate NEBUPENT VIAL-NEB    
praziquantel BILTRICIDE TABLET    
tinidazole TINDAMAX TABLET