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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
BEDAQUILINE FUMARATE SIRTURO TABLET N   Jan 30, 2014
AMINOSALICYLIC ACID PASER GRANPKT DR    
CAPREOMYCIN SULFATE CAPASTAT SULFATE VIAL    
CYCLOSERINE CYCLOSERINE CAPSULE    
ETHAMBUTOL HCL MYAMBUTOL TABLET    
ETHAMBUTOL HCL ETHAMBUTOL HCL TABLET    
ETHIONAMIDE TRECATOR TABLET    
ISONIAZID ISONIAZID SOLUTION    
ISONIAZID ISONIAZID TABLET    
ISONIAZID ISONIAZID VIAL    
PYRAZINAMIDE PYRAZINAMIDE TABLET    
RIFAMP/ISONIAZID/PYRAZINAMIDE RIFATER TABLET    
RIFAMPIN RIFAMPIN CAPSULE    
RIFAMPIN RIFADIN CAPSULE    
RIFAMPIN RIFAMPIN VIAL    
RIFAMPIN RIFADIN VIAL    
RIFAMPIN/ISONIAZID RIFAMATE CAPSULE    
RIFAPENTINE PRIFTIN TABLET