Antimalarials

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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
ARTEMETHER/LUMEFANTRINE COARTEM TABLET    
ATOVAQUONE/PROGUANIL HCL MALARONE TABLET    
ATOVAQUONE/PROGUANIL HCL ATOVAQUONE-PROGUANIL HCL TABLET    
CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE TABLET    
HYDROXYCHLOROQUINE SULFATE PLAQUENIL TABLET    
HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOROQUINE SULFATE TABLET    
MEFLOQUINE HCL MEFLOQUINE HCL TABLET    
PRIMAQUINE PHOSPHATE PRIMAQUINE TABLET    
PYRIMETHAMINE DARAPRIM TABLET    
QUININE SULFATE QUININE SULFATE CAPSULE    
QUININE SULFATE QUALAQUIN CAPSULE