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/D10W CLINIMIX N9G20E 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  
AA 5.5 %/electrolyte-TPN soln TRAVASOL W/ELECTROLYTES IV SOLN PA Document  
AA 5.5 %/electrolyte-TPN soln TRAVASOL WITH ELECTROLYTES IV SOLN PA Document  
alanine/glutamic acid/glycine TRIAMINO TABLET    
amino ac 3%/electrolyte/glycer PROCALAMINE IV SOLN PA Document  
amino acid 4.25 %/dextrose 25% CLINIMIX IV SOLN PA Document  
amino acids PROTEINEX TABLET    
amino acids AMINO ACID MEGA TABLET    
amino acids 10 % TROPHAMINE IV SOLN PA Document  
amino acids 10 % TRAVASOL 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 5.5 % TRAVASOL IV SOLN PA Document  
amino acids 5.5 %/dextrose 10% TRAVASOL W/DEXTROSE 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 7 %/dextrose 50 % AMINOSYN KIT PA Document  
amino acids 7 %/electrolytes AMINOSYN WITH ELECTROLYTES IV SOLN PA Document  
amino acids 8 % HEPATAMINE IV SOLN PA Document  
amino acids 8.5 % TRAVASOL IV SOLN PA Document  
amino acids 8.5 %/electrolytes TRAVASOL W/ELECTROLYTES IV SOLN PA Document  
amino acids 8.5 %/electrolytes AMINOSYN WITH ELECTROLYTES IV SOLN PA Document  
amino acids 8.5 %/electrolytes AMINOSYN II WITH ELECTROLYTES IV SOLN PA Document  
amino acids 8.5 %/electrolytes TRAVASOL WITH ELECTROLYTES IV SOLN PA Document  
arginine L-ARGININE TABLET    
arginine ARGININE TABLET    
cysteine HCl L-CYSTEINE SYRINGE PA Document  
cysteine HCl L-CYSTEINE VIAL PA Document  
glutamine NUTRESTORE POWD PACK    
glutamine L-GLUTAMINE TABLET    
glycine GLYCINE POWDER    
levocarnitine tartrate L-CARNITINE CAPSULE    
lysine L-LYSINE TABLET    
lysine LYSINE TABLET    
lysine HCl L-LYSINE TABLET    
phenylalanine L-PHENYLALANINE TABLET    
threonine L-THREONINE TABLET    
tyrosine L-TYROSINE CAPSULE