Parasympathetic Agents

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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
BETHANECHOL CHLORIDE URECHOLINE TABLET    
BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE TABLET    
CEVIMELINE HCL EVOXAC CAPSULE    
CEVIMELINE HCL CEVIMELINE HCL CAPSULE    
EDROPHONIUM CHLORIDE ENLON VIAL    
GUANIDINE HCL GUANIDINE HCL TABLET    
NEOSTIGMINE METHYLSULFATE NEOSTIGMINE METHYLSULFATE VIAL    
PHYSOSTIGMINE SALICYLATE PHYSOSTIGMINE SALICYLATE AMPUL    
PILOCARPINE HCL SALAGEN TABLET    
PILOCARPINE HCL PILOCARPINE HCL TABLET    
PYRIDOSTIGMINE BROMIDE REGONOL AMPUL    
PYRIDOSTIGMINE BROMIDE MESTINON SYRUP    
PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE TABLET    
PYRIDOSTIGMINE BROMIDE MESTINON TABLET    
PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE ER TABLET ER    
PYRIDOSTIGMINE BROMIDE MESTINON TABLET ER