IV Solutions and Misc

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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
SODIUM,POTASSIUM PHOSPHATES PHOS-NAK POWD PACK Y    
0.9 % SODIUM CHLORIDE SODIUM CHLORIDE IV SOLN    
0.9 % SODIUM CHLORIDE SODIUM CHLORIDE PGGYBK PRT    
0.9 % SODIUM CHLORIDE SODIUM CHLORIDE PGY VL PRT    
0.9 % SODIUM CHLORIDE SODIUM CHLORIDE SYRINGE    
0.9 % SODIUM CHLORIDE SODIUM CHLORIDE VIAL    
AA 2.36%/D6.8W/FAT/E-LYTES NO9 PERIKABIVEN EMULSION    
AA 3.31 %/D9.8W/FAT/E-LYTES 10 KABIVEN EMULSION    
CHROMIC CHLORIDE CHROMIUM VIAL    
CUPRIC CHLORIDE COPPER CHLORIDE VIAL    
DEXTROSE 10 % AND 0.2 % NACL DEXTROSE 10%-0.2% NACL DEHP FR BG    
DEXTROSE 10 % AND 0.45 % NACL DEXTROSE 10%-0.45% NACL IV SOLN    
DEXTROSE 10 % IN WATER DEXTROSE IN WATER DEHP FR BG    
DEXTROSE 10 % IN WATER DEXTROSE IN WATER IV SOLN    
DEXTROSE 2.5 % AND 0.45 % NACL DEXTROSE 2.5%-0.45% NACL IV SOLN    
DEXTROSE 20 % IN WATER DEXTROSE IN WATER IV SOLN    
DEXTROSE 25 % IN WATER DEXTROSE IN WATER SYRINGE    
DEXTROSE 30 % IN WATER DEXTROSE IN WATER IV SOLN    
DEXTROSE 40 % IN WATER DEXTROSE IN WATER IV SOLN    
DEXTROSE 5 % AND 0.3 % NACL DEXTROSE 5%-0.33% NACL IV SOLN    
DEXTROSE 5 % AND 0.3 % NACL DEXTROSE 5%-0.3% NACL IV SOLN    
DEXTROSE 5 % AND 0.9 % NACL DEXTROSE 5%-0.9% NACL IV SOLN    
DEXTROSE 5 % IN WATER DEXTROSE IN WATER IV SOLN    
DEXTROSE 5 % IN WATER DEXTROSE IN WATER PGGYBK PRT    
DEXTROSE 5 % IN WATER DEXTROSE IN WATER PGY VL PRT    
DEXTROSE 5 %-0.2 % SOD CHLORID DEXTROSE 5%-0.2% NACL IV SOLN    
DEXTROSE 5 %-0.2 % SOD CHLORID DEXTROSE 5%-0.225% NACL IV SOLN    
DEXTROSE 5 %-0.45 % SOD CHLORD DEXTROSE 5%-0.45% NACL IV SOLN    
DEXTROSE 5%-LACTATED RINGERS DEXTROSE IN LACTATED RINGERS IV SOLN    
DEXTROSE 50 % IN WATER DEXTROSE IN WATER IV SOLN    
DEXTROSE 50 % IN WATER DEXTROSE IN WATER SYRINGE    
DEXTROSE 50 % IN WATER DEXTROSE IN WATER VIAL    
DEXTROSE 70 % IN WATER DEXTROSE IN WATER IV SOLN    
ELECTROLYTE-148 SOLUTION PLASMA-LYTE 148 IV SOLN    
ELECTROLYTE-48 SOLUTION/D5W DEXTROSE 5%-ELECTROLYTE #48 IV SOLN    
ELECTROLYTE-56 SOLUTION/D5W PLASMA-LYTE 56 IN DEXTROSE IV SOLN    
ELECTROLYTE-A SOLUTION PLASMA-LYTE A PH 7.4 IV SOLN    
ELECTROLYTE-M SOLUTION/D5W NORMOSOL-M AND DEXTROSE IV SOLN    
ELECTROLYTE-MB SOLUTION/D5W IONOSOL MB-DEXTROSE 5% IV SOLN    
ELECTROLYTE-P SOLUTION/D5W ISOLYTE P WITH DEXTROSE IV SOLN    
ELECTROLYTE-R (PH 7.4) NORMOSOL-R PH 7.4 IV SOLN    
ELECTROLYTE-R SOLUTION NORMOSOL-R IV SOLN    
ELECTROLYTE-R SOLUTION/D5W NORMOSOL-R AND DEXTROSE IV SOLN    
ELECTROLYTE-S (PH 7.4) ISOLYTE S IV SOLN    
ELECTROLYTE-S SOLUTION ISOLYTE S IV SOLN    
GENISTEIN/CIT ZINC B-G/VIT D3 VP-GSTN CAPSULE    
MAGNESIUM CHLORIDE MAGNESIUM CHLORIDE VIAL    
MAGNESIUM SULFATE MAGNESIUM SULFATE SYRINGE    
MAGNESIUM SULFATE MAGNESIUM SULFATE VIAL    
MAGNESIUM SULFATE IN WATER MAGNESIUM SULFATE IV SOLN    
MAGNESIUM SULFATE IN WATER MAGNESIUM SULFATE PIGGYBACK    
MAGNESIUM SULFATE/D5W MAGNESIUM SULFATE-D5W PIGGYBACK    
MANGANESE CHLORIDE MANGANESE VIAL    
PARENT AMINO AC 5.2 % (RENAL) AMINOSYN-RF IV SOLN    
PARENT. AMINO ACID 8.5 % NO.2 AMINOSYN IV SOLN    
PARENT. AMINO ACID 8.5 % NO.3 AMINOSYN II IV SOLN    
PARENT.AMINO ACID 10% NO5(PED) AMINOSYN-PF IV SOLN    
PARENT.AMINO ACID 7 % NO1(PED) AMINOSYN-PF IV SOLN    
PARENTERAL AMINO ACID 10% NO.1 AMINOSYN II IV SOLN    
PARENTERAL AMINO ACID 10% NO.2 AMINOSYN IV SOLN    
PARENTERAL AMINO ACID 10% NO.4 FREAMINE III IV SOLN    
PARENTERAL AMINO ACID 10% NO.6 TRAVASOL IV SOLN    
PARENTERAL AMINO ACID 10% NO.7 PREMASOL IV SOLN    
PARENTERAL AMINO ACID 15% NO.1 CLINISOL IV SOLN    
PARENTERAL AMINO ACID 15% NO.1 AMINO ACIDS IV SOLN    
PARENTERAL AMINO ACID 15% NO.2 AMINOSYN II IV SOLN    
PARENTERAL AMINO ACID 20% NO.1 PROSOL IV SOLN    
PARENTERAL AMINO ACID 6 % NO.1 PREMASOL IV SOLN    
PERI.DIALYSIS SOLN28-ICO 7.5 % EXTRANEAL ICODEXTRIN DIALYSIS IP SOLN    
PERIT. DIALYSIS 3-4.25 % DEXTR DIANEAL PD-2 W-4.25% DEXTROSE IP SOLN    
PERIT. DIALYSIS NO.6-1.5 % DEX DIANEAL WITH 1.5% DEXTROSE IP SOLN    
PERITON. DIALYSIS 13-DEX 2.5 % DIANEAL PD-2 W-2.5% DEXTROSE IP SOLN    
PERITON. DIALYSIS 4-1.5 % DEXT DIANEAL PD-2 W-1.5% DEXTROSE IP SOLN    
PERITON.DIALYSIS 7-2.5 % DEXTR DIANEAL WITH 2.5% DEXTROSE IP SOLN    
PERITON.DIALYSIS 8-4.25 % DEXT DIANEAL WITH 4.25% DEXTROSE IP SOLN    
POTASSIUM ACETATE POTASSIUM ACETATE VIAL    
POTASSIUM CHLORIDE POTASSIUM CHLORIDE PIGGYBACK    
POTASSIUM CHLORIDE POTASSIUM CHLORIDE VIAL    
POTASSIUM CHLORIDE IN 0.9%NACL POTASSIUM CHL-NORMAL SALINE IV SOLN    
POTASSIUM CHLORIDE IN D5W DEXTROSE 5%-POTASSIUM CHLORIDE IV SOLN    
POTASSIUM CHLORIDE IN LR-D5 POTASSIUM CHLORIDE IN D5LR IV SOLN    
POTASSIUM CHLORIDE-0.45% NACL POTASSIUM CHLORIDE-NACL IV SOLN    
POTASSIUM CHLORIDE/D5-0.2%NACL DEXTROSE 5%-0.2% NACL-KCL IV SOLN    
POTASSIUM CHLORIDE/D5-0.2%NACL DEXTROSE 5%-0.225% NACL-KCL IV SOLN    
POTASSIUM CHLORIDE/D5-0.3%NACL DEXTROSE 5%-0.33% NACL-KCL IV SOLN    
POTASSIUM CHLORIDE/D5-0.45NACL DEXTROSE 5%-0.45% NACL-KCL IV SOLN    
POTASSIUM CHLORIDE/D5-0.45NACL DEXTROSE 5%-1/2NS-KCL IV SOLN    
POTASSIUM CHLORIDE/D5-0.9%NACL DEXTROSE 5%-NS-KCL IV SOLN    
POTASSIUM PHOS,M-BASIC-D-BASIC POTASSIUM PHOSPHATE VIAL    
RINGER'S SOLUTION RINGERS INJECTION IV SOLN    
RINGER'S SOLUTION,LACTATED LACTATED RINGERS IV SOLN    
SELENIUM SELENIUM VIAL    
SOD PHOSPHATE,MONOBASIC-DIBAS SODIUM PHOSPHATE VIAL    
SOD/POT/MAG/CAL/CL/ACET/GLUCON NUTRILYTE VIAL    
SODIUM ACETATE SODIUM ACETATE VIAL    
SODIUM BICARBONATE SODIUM BICARBONATE SYRINGE    
SODIUM BICARBONATE SODIUM BICARBONATE VIAL    
SODIUM BICARBONATE NEUT VIAL    
SODIUM CHLORIDE SODIUM CHLORIDE VIAL    
SODIUM CHLORIDE 0.45 % SODIUM CHLORIDE IV SOLN    
SODIUM CHLORIDE 0.45 % SODIUM CHLORIDE PGGYBK PRT    
SODIUM CHLORIDE 3 % SODIUM CHLORIDE IV SOLN    
SODIUM CHLORIDE 5 % SODIUM CHLORIDE IV SOLN    
SODIUM LACTATE SODIUM LACTATE VIAL    
SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE ENEMA    
SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE ORAL SUSP    
SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE POWDER    
SODIUM/POT/MAG/CALC/CHLOR/ACET TPN ELECTROLYTES VIAL    
SODIUM/POT/MAG/CALC/CHLOR/ACET HYPERLYTE CR VIAL    
ZINC CHLORIDE ZINC CHLORIDE VIAL    
ZINC SULFATE ZINC SULFATE VIAL    
ZINC/COPPER/MANGAN/CHROM/SELEN MULTITRACE-5 VIAL    
ZINC/COPPER/MANGAN/CHROMIC CHL MULTITRACE-4 VIAL    
ZINC/COPPER/MANGAN/CHROMIC CHL TRACE ELEMENTS-4 VIAL