Antispasm Anticholinergics

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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
ATROPINE SULFATE ATROPINE SULFATE SYRINGE    
ATROPINE SULFATE ATROPINE SULFATE VIAL    
DICYCLOMINE HCL BENTYL AMPUL    
DICYCLOMINE HCL DICYCLOMINE HCL CAPSULE    
DICYCLOMINE HCL BENTYL CAPSULE    
DICYCLOMINE HCL DICYCLOMINE HCL SOLUTION    
DICYCLOMINE HCL DICYCLOMINE HCL TABLET    
DICYCLOMINE HCL DICYCLOMINE HCL VIAL    
GLYCOPYRROLATE CUVPOSA SOLUTION    
GLYCOPYRROLATE GLYCOPYRROLATE TABLET    
GLYCOPYRROLATE ROBINUL TABLET    
GLYCOPYRROLATE ROBINUL FORTE TABLET    
GLYCOPYRROLATE GLYCOPYRROLATE VIAL    
GLYCOPYRROLATE ROBINUL VIAL    
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE TAB SUBL    
HYOSCYAMINE SULFATE LEVSIN-SL TAB SUBL    
HYOSCYAMINE SULFATE OSCIMIN SL TAB SUBL    
HYOSCYAMINE SULFATE SYMAX-SL TAB SUBL    
METHSCOPOLAMINE BROMIDE METHSCOPOLAMINE BROMIDE TABLET    
PHENOBARB/HYOSCY/ATROPINE/SCOP DONNATAL ELIXIR    
PHENOBARB/HYOSCY/ATROPINE/SCOP BELLADONNA-PHENOBARBITAL TABLET    
PHENOBARB/HYOSCY/ATROPINE/SCOP DONNATAL TABLET    
PROPANTHELINE BROMIDE PROPANTHELINE BROMIDE TABLET    
SCOPOLAMINE HYDROBROMIDE SCOPOLAMINE HYDROBROMIDE VIAL