Antidiarrheals

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PDL Reference Documents

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.
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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
bismuth subsalicylate PINK BISMUTH ORAL SUSP Y    
bismuth subsalicylate STOMACH RELIEF ORAL SUSP Y    
bismuth subsalicylate KAOPECTATE ORAL SUSP Y    
bismuth subsalicylate PINK BISMUTH ORAL SUSP Y    
bismuth subsalicylate SOOTHE ORAL SUSP Y    
bismuth subsalicylate STOMACH RELIEF ORAL SUSP Y    
bismuth subsalicylate STRESS LIQIUD ORAL SUSP Y    
bismuth subsalicylate PEPTO-BISMOL ORAL SUSP Y    
bismuth subsalicylate STOMACH RELIEF ORIGINAL ORAL SUSP Y    
bismuth subsalicylate DIARRHEA RELIEF ORAL SUSP Y    
bismuth subsalicylate ANTI-DIARRHEAL ORAL SUSP Y    
bismuth subsalicylate DIGESTIVE RELIEF ORAL SUSP Y    
bismuth subsalicylate GERI-PECTATE ORAL SUSP Y    
bismuth subsalicylate KAOPECTATE ORAL SUSP Y    
bismuth subsalicylate KAOPECTATE MAX ORAL SUSP Y    
bismuth subsalicylate K-PEC ORAL SUSP Y    
bismuth subsalicylate BISMUTH TAB CHEW Y    
bismuth subsalicylate STOMACH RELIEF TAB CHEW Y    
bismuth subsalicylate PINK BISMUTH TAB CHEW Y    
bismuth subsalicylate PEPTO-BISMOL TO-GO TAB CHEW Y    
bismuth subsalicylate PINK BISMUTH TAB CHEW Y    
bismuth subsalicylate SOOTHE TAB CHEW Y    
bismuth subsalicylate STOMACH RELIEF TAB CHEW Y    
bismuth subsalicylate PEPTO-BISMOL TAB CHEW Y    
bismuth subsalicylate DIOTAME TAB CHEW Y    
bismuth subsalicylate KAOPECTATE TAB CHEW Y    
bismuth subsalicylate PEP-T-MED TAB CHEW Y    
bismuth subsalicylate BISMUTH TAB CHEW Y    
bismuth subsalicylate STOMACH RELIEF TABLET Y    
bismuth subsalicylate PINK BISMUTH TABLET Y    
bismuth subsalicylate PINK BISMUTH TABLET Y    
bismuth subsalicylate SOOTHE TABLET Y    
bismuth subsalicylate STOMACH RELIEF TABLET Y    
bismuth subsalicylate PEPTO-BISMOL TABLET Y    
bismuth subsalicylate DIGESTIVE RELIEF TABLET Y    
bismuth subsalicylate KAOPECTATE TABLET Y    
diphenoxylate HCl/atropine DIPHENOXYLATE-ATROPINE TABLET Y    
diphenoxylate HCl/atropine LOMOTIL TABLET Y    
loperamide HCl ANTI-DIARRHEAL CAPSULE Y Quantity Limit  
loperamide HCl IMODIUM A-D CAPSULE Y Quantity Limit  
loperamide HCl ANTI-DIARRHEAL CAPSULE Y Quantity Limit  
loperamide HCl LOPERAMIDE CAPSULE Y Quantity Limit  
loperamide HCl ANTI-DIARRHEAL LIQUID Y Quantity Limit  
loperamide HCl IMODIUM A-D LIQUID Y Quantity Limit  
loperamide HCl LOPERAMIDE LIQUID Y Quantity Limit  
loperamide HCl LOPERAMIDE HCL LIQUID Y Quantity Limit  
loperamide HCl ANTI-DIARRHEAL LIQUID Y Quantity Limit  
loperamide HCl LOPERAMIDE LIQUID Y Quantity Limit  
loperamide HCl LOPERAMIDE HCL LIQUID Y Quantity Limit  
loperamide HCl ULTRA A-D TABLET Y Quantity Limit  
loperamide HCl ANTI-DIARRHEAL TABLET Y Quantity Limit  
loperamide HCl DIAMODE TABLET Y Quantity Limit  
loperamide HCl IMODIUM A-D TABLET Y Quantity Limit  
loperamide HCl LOPERAMIDE TABLET Y Quantity Limit  
loperamide HCl LOPERAMIDE HCL TABLET Y Quantity Limit  
loperamide HCl ANTI-DIARRHEAL TABLET Y Quantity Limit  
alosetron HCl ALOSETRON HCL TABLET N Pharmacy PA  
alosetron HCl LOTRONEX TABLET N Pharmacy PA  
attapulgite KAO-TIN ORAL SUSP N    
crofelemer MYTESI TABLET DR N    
difenoxin HCl/atropine sulfate MOTOFEN TABLET N    
diphenoxylate HCl/atropine DIPHENOXYLATE-ATROPINE LIQUID N    
eluxadoline VIBERZI TABLET N Pharmacy PA Mar 31, 2016
loperamide HCl/simethicone LOPERAMIDE-SIMETHICONE TABLET N Quantity Limit  
loperamide HCl/simethicone ANTI-DIARRHEAL-ANTI-GAS TABLET N Quantity Limit  
opium tincture OPIUM TINCTURE TINCTURE N    
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