Protein Lysates

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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
AA 2.75 %/CALCIUM/LYTES/D10W CLINIMIX E IV SOLN PA Document  
AA 2.75 %/CALCIUM/LYTES/D5W CLINIMIX E IV SOLN PA Document  
AA 4.25 %/CALCIUM/LYTES/D25W CLINIMIX E IV SOLN PA Document  
AA 4.25 %/CALCIUM/LYTES/D5W CLINIMIX E IV SOLN PA Document  
AA 4.25%/CALCIUM/LYTES/DEX 10% CLINIMIX E IV SOLN PA Document  
AA 5 %/CALCIUM/LYTES/DEXT 20 % CLINIMIX E IV SOLN PA Document  
AA 5 %/CALCIUM/LYTES/DEXT 25 % CLINIMIX E IV SOLN PA Document  
AMINO AC 3%/ELECTROLYTE/GLYCER PROCALAMINE IV SOLN PA Document  
AMINO ACID 4.25 %/DEXTROSE 25% CLINIMIX IV SOLN PA Document  
AMINO ACIDS 10 % TROPHAMINE IV SOLN PA Document  
AMINO ACIDS 2.75 %/D5W CLINIMIX IV SOLN PA Document  
AMINO ACIDS 3.5%/ELECTROLYTE M AMINOSYN M IV SOLN PA Document  
AMINO ACIDS 4.25 %/DEXTROSE 5% CLINIMIX IV SOLN PA Document  
AMINO ACIDS 4.25%/DEXTROSE 10% CLINIMIX IV SOLN PA Document  
AMINO ACIDS 4.25%/DEXTROSE 20% CLINIMIX IV SOLN PA Document  
AMINO ACIDS 5 %/DEXTROSE 15 % CLINIMIX IV SOLN PA Document  
AMINO ACIDS 5 %/DEXTROSE 20 % CLINIMIX IV SOLN PA Document  
AMINO ACIDS 5 %/DEXTROSE 25 % CLINIMIX IV SOLN PA Document  
AMINO ACIDS 5.4 % NEPHRAMINE IV SOLN PA Document  
AMINO ACIDS 6 % TROPHAMINE IV SOLN PA Document  
AMINO ACIDS 6.9 % FREAMINE HBC IV SOLN PA Document  
AMINO ACIDS 7 % AMINOSYN-HBC IV SOLN PA Document  
AMINO ACIDS 8 % HEPATAMINE IV SOLN PA Document  
AMINO ACIDS 8.5 %/ELECTROLYTES AMINOSYN II WITH ELECTROLYTES IV SOLN PA Document  
AMINO ACIDS 8.5 %/ELECTROLYTES AMINOSYN WITH ELECTROLYTES IV SOLN PA Document  
CYSTEINE HCL L-CYSTEINE VIAL PA Document  
GLUTAMINE NUTRESTORE POWD PACK