Antidotes

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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
ACETYLCYSTEINE CETYLEV TABLET EFF    
ACETYLCYSTEINE ACETYLCYSTEINE VIAL    
ACETYLCYSTEINE ACETADOTE VIAL    
ACTIVATED CHARCOAL ACTIDOSE-AQUA ORAL SUSP    
ACTIVATED CHARCOAL EZ CHAR SUSP RECON    
AMIFOSTINE CRYSTALLINE ETHYOL VIAL    
AMIFOSTINE CRYSTALLINE AMIFOSTINE VIAL    
ANTIVENIN,LATRODECTUS MACTANS ANTIVENIN LATRODECTUS MACTANS VIAL    
ANTIVENIN,MICRURUS FULVIUS ANTIVENIN MICRURUS FULVIUS VIAL    
CENTRUROIDES(SCORPN) ANTIVENOM ANASCORP VIAL    
CHARCOAL/SORBITOL SOLUTION ACTIDOSE ORAL SUSP    
DEXRAZOXANE HCL ZINECARD VIAL    
DEXRAZOXANE HCL DEXRAZOXANE VIAL    
DIMERCAPROL BAL IN OIL AMPUL    
EDETATE CALCIUM DISODIUM CALCIUM DISODIUM VERSENATE AMPUL    
FOMEPIZOLE FOMEPIZOLE VIAL    
LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM TABLET    
LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM VIAL    
LEVOLEUCOVORIN CALCIUM FUSILEV VIAL    
LEVOLEUCOVORIN CALCIUM LEVOLEUCOVORIN CALCIUM VIAL    
MESNA MESNEX TABLET    
MESNA MESNA VIAL    
MESNA MESNEX VIAL    
METHYLENE BLUE PROVAYBLUE AMPUL    
METHYLENE BLUE METHYLENE BLUE VIAL    
PRALIDOXIME CHLORIDE PROTOPAM CHLORIDE VIAL    
SUCCIMER CHEMET CAPSULE    
TRIENTINE HCL SYPRINE CAPSULE    
ZINC ACETATE GALZIN CAPSULE