IV Solutions and Misc
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.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| 0.9 % sodium chloride | SODIUM CHLORIDE | AMPUL | N | |||
| 0.9 % sodium chloride | SODIUM CHLORIDE | IV SOLN | N | |||
| 0.9 % sodium chloride | SODIUM CHLORIDE | PGGYBK PRT | N | |||
| 0.9 % sodium chloride | SODIUM CHLORIDE | PGY VL PRT | N | |||
| 0.9 % sodium chloride | SODIUM CHLORIDE | VIAL | N | |||
| AA 2.36%/D7.5W/fat/e-lytes no9 | PERIKABIVEN | EMULSION | N | |||
| AA 2.75 % no.2/D5W/lytes no.29 | CLINIMIX E | IV SOLN | N | |||
| AA 3.31 %/D10.8W/fat/e-lyt 10 | KABIVEN | EMULSION | N | |||
| AA 4.25 % no.1/D5W/lytes no.39 | CLINIMIX E | IV SOLN | N | |||
| AA 4.25 % no.1/dextrose 10 % | CLINIMIX | IV SOLN | N | |||
| AA 4.25 % no.1/dextrose 5 % | CLINIMIX | IV SOLN | N | |||
| AA 4.25% no.1/D10W/lytes no.39 | CLINIMIX E | IV SOLN | N | |||
| AA 5 % no.6/D15W/lytes no.23 | CLINIMIX E | IV SOLN | N | |||
| AA 5 % no.6/D20W/lytes no.23 | CLINIMIX E | IV SOLN | N | |||
| AA 5 % no.6/dextrose 15 % | CLINIMIX | IV SOLN | N | |||
| AA 5 % no.6/dextrose 20 % | CLINIMIX | IV SOLN | N | |||
| amino ac 8 %/D10W/electrolytes | CLINIMIX E | IV SOLN | N | |||
| amino ac 8 %/D14W/electrolytes | CLINIMIX E | IV SOLN | N | |||
| amino acid 6 % in 5 % dextrose | CLINIMIX | IV SOLN | N | |||
| amino acid 8 % in D10W | CLINIMIX | IV SOLN | N | |||
| amino acid 8 % in D14W | CLINIMIX | IV SOLN | N | |||
| amino acids 10 % | TRAVASOL | IV SOLN | N | |||
| amino acids 10 % | TROPHAMINE | IV SOLN | N | |||
| amino acids 7 % | AMINOSYN-HBC | IV SOLN | N | |||
| amino acids 7 %/electrolytes | AMINOSYN WITH ELECTROLYTES | IV SOLN | N | |||
| amino acids 8.5 % | TRAVASOL | IV SOLN | N | |||
| amino acids 8.5 %/electrolytes | TRAVASOL WITH ELECTROLYTES | IV SOLN | N | |||
| amino acids 8.5 %/electrolytes | AMINOSYN WITH ELECTROLYTES | IV SOLN | N | |||
| amino acids 8.5 %/electrolytes | TRAVASOL W/ELECTROLYTES | IV SOLN | N | |||
| calcium chloride | CALCIUM CHLORIDE | SYRINGE | N | |||
| calcium chloride | CALCIUM CHLORIDE | VIAL | N | |||
| calcium gluc in NaCl, iso-osm | CALCIUM GLUCONATE-NACL | PLAST. BAG | N | |||
| calcium gluconate | CALCIUM GLUCONATE | AMPUL | N | |||
| calcium gluconate | CALCIUM GLUCONATE | VIAL | N | |||
| chromic chloride | CHROMIC CHLORIDE | VIAL | N | |||
| chromic chloride | CHROMIUM | VIAL | N | |||
| chromium | CHROMIUM | TABLET | N | |||
| copper gluconate | COPPER | TABLET | N | |||
| cupric chloride | COPPER CHLORIDE | VIAL | N | |||
| cupric chloride | CUPRIC CHLORIDE | VIAL | N | |||
| dex 2.5%-half str lact.ringers | DEXTROSE IN LACTATED RINGERS | IV SOLN | N | |||
| dextrose 10 % and 0.2 % NaCl | DEXTROSE 10%-0.2% NACL | DEHP FR BG | N | |||
| dextrose 10 % and 0.2 % NaCl | DEXTROSE 10%-1/4NS | IV SOLN | N | |||
| dextrose 10 % and 0.45 % NaCl | DEXTROSE 10%-0.45% NACL | IV SOLN | N | |||
| dextrose 10 % and 0.9 % NaCl | DEXTROSE WITH SODIUM CHLORIDE | IV SOLN | N | |||
| dextrose 10 % in water | DEXTROSE IN WATER | DEHP FR BG | N | |||
| dextrose 10 % in water | DEXTROSE IN WATER | IV SOLN | N | |||
| dextrose 2.5 % and 0.45 % NaCl | DEXTROSE 2.5%-0.45% NACL | IV SOLN | N | |||
| dextrose 2.5 % and 0.45 % NaCl | DEXTROSE WITH SODIUM CHLORIDE | IV SOLN | N | |||
| dextrose 2.5 % in water | DEXTROSE IN WATER | IV SOLN | N | |||
| dextrose 2.5% in half ringers | DEXTROSE IN RINGERS INJECTION | IV SOLN | N | |||
| dextrose 20 % in water | DEXTROSE IN WATER | IV SOLN | N | |||
| dextrose 25 % in water | DEXTROSE IN WATER | SYRINGE | N | |||
| dextrose 30 % in water | DEXTROSE IN WATER | IV SOLN | N | |||
| dextrose 40 % in water | DEXTROSE IN WATER | IV SOLN | N | |||
| dextrose 5 % and 0.3 % NaCl | DEXTROSE 5%-0.3% NACL | IV SOLN | N | |||
| dextrose 5 % and 0.3 % NaCl | DEXTROSE 5%-0.33% NACL | IV SOLN | N | |||
| dextrose 5 % and 0.3 % NaCl | DEXTROSE WITH SODIUM CHLORIDE | IV SOLN | N | |||
| dextrose 5 % and 0.9 % NaCl | DEXTROSE 5%-0.9% NACL | IV SOLN | N | |||
| dextrose 5 % and 0.9 % NaCl | GLUCOSE 5%-0.9% NACL | IV SOLN | N | |||
| dextrose 5 % in Ringer's | DEXTROSE IN RINGERS INJECTION | IV SOLN | N | |||
| dextrose 5 % in water | DEXTROSE IN WATER | IV SOLN | N | |||
| dextrose 5 % in water | GLUCOSE IN WATER | IV SOLN | N | |||
| dextrose 5 % in water | DEXTROSE IN WATER | PGGYBK PRT | N | |||
| dextrose 5 % in water | DEXTROSE IN WATER | PGY VL PRT | N | |||
| dextrose 5 % in water | DEXTROSE IN WATER | VIAL | N | |||
| dextrose 5 %-0.2 % sod chlorid | DEXTROSE 5%-0.225% NACL | IV SOLN | N | |||
| dextrose 5 %-0.2 % sod chlorid | DEXTROSE 5%-0.2% NACL | IV SOLN | N | |||
| dextrose 5 %-0.2 % sod chlorid | DEXTROSE WITH SODIUM CHLORIDE | IV SOLN | N | |||
| dextrose 5 %-0.45 % sod chlord | DEXTROSE WITH SODIUM CHLORIDE | IV SOLN | N | |||
| dextrose 5 %-0.45 % sod chlord | DEXTROSE 5%-0.45% NACL | IV SOLN | N | |||
| dextrose 5%-lactated ringers | DEXTROSE IN LACTATED RINGERS | IV SOLN | N | |||
| dextrose 50 % in water | GLUCOSE IN WATER | IV SOLN | N | |||
| dextrose 50 % in water | DEXTROSE IN WATER | IV SOLN | N | |||
| dextrose 50 % in water | DEXTROSE IN WATER | SYRINGE | N | |||
| dextrose 50 % in water | DEXTROSE IN WATER | VIAL | N | |||
| dextrose 60 % in water | DEXTROSE IN WATER | IV SOLN | N | |||
| dextrose 70 % in water | DEXTROSE IN WATER | IV SOLN | N | |||
| dextrose 70 % in water | GLUCOSE IN WATER | IV SOLN | N | |||
| dietary supplement | SCANDIBAR | BAR | Pharmacy PA | N | ||
| e-lytes/carboxymethylcellulose | SALIVA SUBSTITUTE | SOLUTION | N | |||
| electrolyte solution,inj | HYPERLYTE R | VIAL | N | |||
| electrolyte solution,inj | HYPERLYTE | VIAL | N | |||
| electrolyte-148 (pH 7.4) | PLASMA-LYTE 148 PH 7.4 | IV SOLN | N | |||
| electrolyte-148 solution | MULTIPLE ELECTROLYTES T1 PH5.5 | IV SOLN | N | |||
| Electrolyte-2/Invert Sugar 5% | TRAVERT-ELECTROLYTE NO.2 | IV SOLN | N | |||
| Electrolyte-4/Invert Sugar 5% | TRAVERT-ELECTROLYTE NO.4 | IV SOLN | N | |||
| electrolyte-48 solution/D5W | DEXTROSE 5%-ELECTROLYTE #48 | IV SOLN | N | |||
| Electrolyte-48/fructose 10 % | FRUCTOSE-ELECTROLYTE NO.48 | IV SOLN | N | |||
| Electrolyte-48/fructose 5 % | FRUCTOSE-ELECTROLYTE NO.48 | IV SOLN | N | |||
| electrolyte-75 solution/D5W | DEXTROSE 5%-ELECTROLYTE #75 | IV SOLN | N | |||
| Electrolyte-75/fructose 5 % | FRUCTOSE-ELECTROLYTE NO.75 | IV SOLN | N | |||
| electrolyte-A solution | MULTIPLE ELECTROLYTES T1 PH7.4 | IV SOLN | N | |||
| electrolyte-A solution | PLASMA-LYTE A | IV SOLN | N | |||
| electrolyte-A solution | PLASMA-LYTE A PH 7.4 | IV SOLN | N | |||
| electrolyte-B solution/D50W | DEXTROSE W/ELECTROLYTE B | IV SOLN | N | |||
| electrolyte-M solution/D5W | PLASMA-LYTE M IN DEXTROSE | IV SOLN | N | |||
| electrolyte-M solution/D5W | NORMOSOL-M AND DEXTROSE | IV SOLN | N | |||
| electrolyte-MB solution/D5W | IONOSOL MB-DEXTROSE 5% | IV SOLN | N | |||
| electrolyte-P solution/D5W | ISOLYTE P WITH DEXTROSE | IV SOLN | N | |||
| electrolyte-R (ph 7.4) | NORMOSOL-R PH 7.4 | IV SOLN | N | |||
| electrolyte-R solution | NORMOSOL-R | IV SOLN | N | |||
| electrolyte-R solution/D5W | NORMOSOL-R AND DEXTROSE | IV SOLN | N | |||
| electrolyte-S (ph 7.4) | ISOLYTE S | IV SOLN | N | |||
| electrolyte-S in 5 % dextrose | ISOLYTE S WITH DEXTROSE | IV SOLN | N | |||
| electrolyte-S solution | ISOLYTE S | IV SOLN | N | |||
| electrolytes,oral/multivit/AAs | HYDRATING ELECTROLYTE SF | POWD PACK | N | |||
| electrolytes/dextrose | HYDRATING ELECTROLYTE | PACKET | N | |||
| electrolytes/dextrose | WELL LYTE ADVANCED HYDRATION | SOLUTION | N | |||
| electrolytes/dextrose | ORALYTE | SOLUTION | N | |||
| electrolytes/dextrose | PEDIALYTE | SOLUTION | N | |||
| electrolytes/dextrose | PEDIALYTE ELECTROLYTE SINGLES | SOLUTION | N | |||
| electrolytes/dextrose | PEDIATRIC ELECTROLYTE | SOLUTION | N | |||
| electrolytes/dextrose | TRUELYTE ADVANCED HYDRATION | SOLUTION | N | |||
| fructose 10 % | FRUCTOSE | IV SOLN | N | |||
| intraventricular electrolytes1 | INTRAVENTRICULAR ELECTROLYTES | VIAL | N | |||
| inverted sugar 10 % | TRAVERT | IV SOLN | N | |||
| inverted sugar 10% in 0.9%NaCl | TRAVERT IN NORMAL SALINE | IV SOLN | N | |||
| inverted sugar 5 % | TRAVERT | IV SOLN | N | |||
| KCl in inverted sugar 10%-NaCl | TRAVERT-1/2 NS WITH KCL | IV SOLN | N | |||
| Lytes/inverted sugar 10 % | TRAVERT-ELECTROLYTE NO.3 | IV SOLN | N | |||
| Lytes/inverted sugar 10 % | TRAVERT-ELECTROLYTE NO.1 | IV SOLN | N | |||
| Lytes/inverted sugar 10 % | TRAVERT-ELECTROLYTE NO.2 | IV SOLN | N | |||
| magnesium carbonate/sod bicarb | RENACARB | TABLET DR | N | |||
| magnesium chloride | MAGNESIUM CHLORIDE | VIAL | N | |||
| magnesium sulfate | MAGNESIUM SULFATE | SYRINGE | N | |||
| magnesium sulfate | MAGNESIUM SULFATE | VIAL | N | |||
| magnesium sulfate in water | MAGNESIUM SULFATE | IV SOLN | N | |||
| magnesium sulfate in water | MAGNESIUM SULFATE | PIGGYBACK | N | |||
| magnesium sulfate/D5W | MAGNESIUM SULFATE-D5W | INFUS. BTL | N | |||
| magnesium sulfate/D5W | MAGNESIUM SULFATE-D5W | PIGGYBACK | N | |||
| manganese chloride | MANGANESE | VIAL | N | |||
| manganese chloride | MANGANESE CHLORIDE | VIAL | N | |||
| nutritional supplement | NUTREN 2.0 | LIQUID | Pharmacy PA | N | ||
| nutritional supplement | REABILAN | LIQUID | Pharmacy PA | N | ||
| nutritional supplement | REABILANHN | LIQUID | Pharmacy PA | N | ||
| nutritional supplement | NUBASICS | POWDER | Pharmacy PA | N | ||
| parent amino ac 5.2 % (renal) | AMINOSYN-RF | IV SOLN | N | |||
| parent. amino acid 8.5 % no.3 | AMINOSYN II | IV SOLN | N | |||
| parent.amino acid 10% no5(ped) | AMINOSYN-PF | IV SOLN | N | |||
| parent.amino acid 7 % no1(ped) | AMINOSYN-PF | IV SOLN | N | |||
| parenteral amino acid 10% no.1 | AMINOSYN II | IV SOLN | N | |||
| parenteral amino acid 10% no.6 | TRAVASOL | IV SOLN | N | |||
| parenteral amino acid 10% no.7 | PREMASOL | IV SOLN | N | |||
| parenteral amino acid 15% no.1 | NOVAMINE | IV SOLN | N | |||
| parenteral amino acid 15% no.2 | AMINOSYN II | IV SOLN | N | |||
| parenteral amino acid 15% no.5 | CLINISOL | IV SOLN | N | |||
| parenteral amino acid 15% no.6 | PLENAMINE | IV SOLN | N | |||
| parenteral amino acid 20% no.1 | PROSOL | IV SOLN | N | |||
| parenteral amino acid 7 % no.2 | AMINOSYN II | IV SOLN | N | |||
| peri.dialysis soln28-ico 7.5 % | EXTRANEAL ICODEXTRIN DIALYSIS | IP SOLN | N | |||
| perit. dialysis 19-dextr 1.5 % | DELFLEX WITH 1.5% DEXTROSE | IP SOLN | N | |||
| perit. dialysis 21-2.5 % dextr | DELFLEX WITH 2.5% DEXTROSE | IP SOLN | N | |||
| perit. dialysis 3-dextr 4.25 % | DIALYTE LM W/DEXTROSE 4.25% | IP SOLN | N | |||
| perit. dialysis 3-dextr 4.25 % | DIANEAL PD-2 W-4.25% DEXTROSE | IP SOLN | N | |||
| perit. dialysis no.6-dex 1.5 % | DIANEAL PD4 WITH 1.36% GLUCOSE | IP SOLN | N | |||
| perit. dialysis no.6-dex 1.5 % | DELFLEX WITH 1.5% DEXTROSE | IP SOLN | N | |||
| perit. dialysis no.6-dex 1.5 % | DIANEAL PD-4 WITH 1.5% DEXTROS | IP SOLN | N | |||
| perit. dialysis no.6-dex 1.5 % | DIANEAL WITH 1.5% DEXTROSE | IP SOLN | N | |||
| periton. dialysis 13-dex 2.5 % | DIALYTE LM W/DEXTROSE 2.5% | IP SOLN | N | |||
| periton. dialysis 13-dex 2.5 % | DIANEAL PD-2 W-2.5% DEXTROSE | IP SOLN | N | |||
| periton. dialysis 4-dext 1.5 % | DIALYTE LM W/DEXTROSE 1.5% | IP SOLN | N | |||
| periton. dialysis 4-dext 1.5 % | DIANEAL PD-2 W-1.5% DEXTROSE | IP SOLN | N | |||
| periton.dialysis 7-dextr 2.5 % | DELFLEX WITH 2.5% DEXTROSE | IP SOLN | N | |||
| periton.dialysis 7-dextr 2.5 % | DIANEAL PD4 WITH 2.27% GLUCOSE | IP SOLN | N | |||
| periton.dialysis 7-dextr 2.5 % | DIANEAL PD-4 WITH 2.5% DEXTROS | IP SOLN | N | |||
| periton.dialysis 7-dextr 2.5 % | DIANEAL WITH 2.5% DEXTROSE | IP SOLN | N | |||
| periton.dialysis 8-dext 4.25 % | DELFLEX WITH 4.25% DEXTROSE | IP SOLN | N | |||
| periton.dialysis 8-dext 4.25 % | DIANEAL PD-4 WITH 4.25% DEXTR | IP SOLN | N | |||
| periton.dialysis 8-dext 4.25 % | DIANEAL WITH 4.25% DEXTROSE | IP SOLN | N | |||
| periton.dialysis 8-dext 4.25 % | DIANEAL PD4 WITH 3.86% GLUCOSE | IP SOLN | N | |||
| potassium acetate | POTASSIUM ACETATE | VIAL | N | |||
| potassium chloride | POTASSIUM CHLORIDE | IV SOLN | N | |||
| potassium chloride | POTASSIUM CHLORIDE | VIAL | N | |||
| potassium chloride in 0.9%NaCl | POTASSIUM CHL-NORMAL SALINE | IV SOLN | N | |||
| potassium chloride in 0.9%NaCl | POTASSIUM CHLORIDE-0.9% NACL | IV SOLN | N | |||
| potassium chloride in D5W | DEXTROSE 5%-POTASSIUM CHLORIDE | IV SOLN | N | |||
| potassium chloride in D5W | POTASSIUM CHLORIDE-DEXTROSE 5% | IV SOLN | N | |||
| potassium chloride in LR-D5 | POTASSIUM CHLORIDE IN D5LR | IV SOLN | N | |||
| potassium chloride in water | POTASSIUM CHLORIDE | PIGGYBACK | N | |||
| potassium chloride-0.45% NaCl | POTASSIUM CHLORIDE-0.45% NACL | IV SOLN | N | |||
| potassium chloride/D5-0.2%NaCl | DEXTROSE 5%-1/4NS-KCL | IV SOLN | N | |||
| potassium chloride/D5-0.2%NaCl | KCL-D5W-0.225% NACL | IV SOLN | N | |||
| potassium chloride/D5-0.2%NaCl | KCL-D5W-0.2% NACL | IV SOLN | N | |||
| potassium chloride/D5-0.3%NaCl | DEXTROSE 5%-1/3NS-KCL | IV SOLN | N | |||
| potassium chloride/D5-0.3%NaCl | KCL-D5W-0.3% NACL | IV SOLN | N | |||
| potassium chloride/D5-0.45NaCl | DEXTROSE 5%-1/2NS-KCL | IV SOLN | N | |||
| potassium chloride/D5-0.45NaCl | KCL-D5W-0.45% NACL | IV SOLN | N | |||
| potassium chloride/D5-0.9%NaCl | KCL-D5W-0.9% NACL | IV SOLN | N | |||
| potassium phos in 0.9 % NaCl | POTASSIUM PHOSPHATE-0.9% NACL | PIGGYBACK | N | |||
| potassium phos in 0.9 % NaCl | POTASSIUM PHOSPHATE-0.9% NACL | PLAST. BAG | N | |||
| potassium phos,m-basic-d-basic | POTASSIUM PHOSPHATE | VIAL | N | |||
| potassium phos,m-basic-d-basic | POTASSIUM PHOSPHATES | VIAL | N | |||
| Ringer's solution | RINGERS INJECTION | IV SOLN | N | |||
| Ringer's solution,lactated | LACTATED RINGERS | IV SOLN | N | |||
| selenium | SELENIOUS ACID | VIAL | N | |||
| sod phosphate,monobasic-dibas | SODIUM PHOSPHATE | VIAL | N | |||
| sodium acetate | SODIUM ACETATE | VIAL | N | |||
| sodium bicarbonate | SODIUM BICARBONATE | IV SOLN | N | |||
| sodium bicarbonate | SODIUM BICARBONATE | SYRINGE | N | |||
| sodium bicarbonate | SODIUM BICARBONATE | VIAL | N | |||
| sodium chloride | SODIUM CHLORIDE | SOLUTION | N | |||
| sodium chloride | SODIUM CHLORIDE | TABLET SOL | N | |||
| sodium chloride | SODIUM CHLORIDE | VIAL | N | |||
| sodium chloride 0.325 % | SODIUM CHLORIDE | SYRINGE | N | |||
| sodium chloride 0.45 % | SODIUM CHLORIDE | IV SOLN | N | |||
| sodium chloride 0.45 % | SODIUM CHLORIDE | PGGYBK PRT | N | |||
| sodium chloride 0.9 % (flush) | SODIUM CHLORIDE | SYRINGE | N | |||
| sodium chloride 3 % | SODIUM CHLORIDE | IV SOLN | N | |||
| sodium chloride 5 % | SODIUM CHLORIDE | IV SOLN | N | |||
| sodium glycerophosphate | GLYCOPHOS | VIAL | N | |||
| sodium lactate | SODIUM LACTATE | IV SOLN | N | |||
| sodium polystyrene sulfonate | SODIUM POLYSTYRENE SULFONATE | POWDER | N | |||
| sodium/pot/mag/calc/chlor/acet | TPN ELECTROLYTES | VIAL | N | |||
| trace elements comb no.1 | ADDAMEL N | AMPUL | N | |||
| triheptanoin | DOJOLVI | LIQUID | Pharmacy PA | N | ||
| tromethamine | TROMETHAMINE | IV SOLN | N | |||
| tromethamine | THAM | IV SOLN | N | |||
| vit C/Zn gluc/herbal no.325 | ELDERBERRY ZINC | LOZENGE | N | |||
| zinc amino acid chelate | ZINC CHELATED | TABLET | N | |||
| zinc chloride | ZINC CHLORIDE | VIAL | N | |||
| zinc sulfate | VERAZINC | CAPSULE | N | |||
| zinc sulfate | ZINC SULFATE | VIAL | N | |||
| zinc/copper/manganese/selenium | MULTRYS | VIAL | N | |||
| zinc/copper/manganese/selenium | TRALEMENT | VIAL | N | |||
| Zn/Cu/mang/selen/fluor/pot iod | PEDITRACE | VIAL | N |