Cephalosporins (3rd Gen), Oral

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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.
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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00093316006 CEFDINIR cefdinir CAPSULE 300 mg Y Y N  
00904756304 CEFDINIR cefdinir CAPSULE 300 mg Y N  
57237009960 CEFDINIR cefdinir CAPSULE 300 mg Y Y N  
60687069911 CEFDINIR cefdinir CAPSULE 300 mg Y Y N  
60687069921 CEFDINIR cefdinir CAPSULE 300 mg Y Y N  
65862017760 CEFDINIR cefdinir CAPSULE 300 mg Y Y N  
67877054360 CEFDINIR cefdinir CAPSULE 300 mg Y Y N  
68001036206 CEFDINIR cefdinir CAPSULE 300 mg Y Y N  
68180071160 CEFDINIR cefdinir CAPSULE 300 mg Y Y N  
00093413664 CEFDINIR cefdinir SUSP RECON 125 mg/5 mL Y Y N  
00093413673 CEFDINIR cefdinir SUSP RECON 125 mg/5 mL Y Y N  
65862021801 CEFDINIR cefdinir SUSP RECON 125 mg/5 mL Y Y N  
65862021860 CEFDINIR cefdinir SUSP RECON 125 mg/5 mL Y Y N  
67877054788 CEFDINIR cefdinir SUSP RECON 125 mg/5 mL Y Y N  
67877054798 CEFDINIR cefdinir SUSP RECON 125 mg/5 mL Y Y N  
68180072204 CEFDINIR cefdinir SUSP RECON 125 mg/5 mL Y Y N  
68180072205 CEFDINIR cefdinir SUSP RECON 125 mg/5 mL Y Y N  
00093413764 CEFDINIR cefdinir SUSP RECON 250 mg/5 mL Y Y N  
00093413773 CEFDINIR cefdinir SUSP RECON 250 mg/5 mL Y Y N  
65862021901 CEFDINIR cefdinir SUSP RECON 250 mg/5 mL Y Y N  
65862021960 CEFDINIR cefdinir SUSP RECON 250 mg/5 mL Y Y N  
67877054888 CEFDINIR cefdinir SUSP RECON 250 mg/5 mL Y Y N  
67877054898 CEFDINIR cefdinir SUSP RECON 250 mg/5 mL Y Y N  
68180072304 CEFDINIR cefdinir SUSP RECON 250 mg/5 mL Y Y N  
68180072305 CEFDINIR cefdinir SUSP RECON 250 mg/5 mL Y Y N  
67877058433 CEFIXIME cefixime CAPSULE 400 mg N Y N  
67877058450 CEFIXIME cefixime CAPSULE 400 mg N Y N  
68180042308 CEFIXIME cefixime CAPSULE 400 mg N Y N  
68180042311 CEFIXIME cefixime CAPSULE 400 mg N Y N  
65862075150 CEFIXIME cefixime SUSP RECON 100 mg/5 mL N Y N  
65862075250 CEFIXIME cefixime SUSP RECON 200 mg/5 mL N Y N  
65862075275 CEFIXIME cefixime SUSP RECON 200 mg/5 mL N Y N  
68180040703 CEFIXIME cefixime SUSP RECON 200 mg/5 mL N Y N  
68180040704 CEFIXIME cefixime SUSP RECON 200 mg/5 mL N Y N  
16714040301 CEFPODOXIME PROXETIL cefpodoxime proxetil SUSP RECON 100 mg/5 mL N Y N  
16714040302 CEFPODOXIME PROXETIL cefpodoxime proxetil SUSP RECON 100 mg/5 mL N Y N  
64980040310 CEFPODOXIME PROXETIL cefpodoxime proxetil SUSP RECON 100 mg/5 mL N Y N  
64980040350 CEFPODOXIME PROXETIL cefpodoxime proxetil SUSP RECON 100 mg/5 mL N Y N  
16714040201 CEFPODOXIME PROXETIL cefpodoxime proxetil SUSP RECON 50 mg/5 mL N Y N  
16714040202 CEFPODOXIME PROXETIL cefpodoxime proxetil SUSP RECON 50 mg/5 mL N Y N  
00781543820 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 100 mg N Y N  
16714039401 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 100 mg N Y N  
65862009501 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 100 mg N Y N  
65862009520 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 100 mg N Y N  
67877087820 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 100 mg N Y N  
69292051001 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 100 mg N Y N  
69292051401 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 100 mg N Y N  
69292051450 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 100 mg N Y N  
00781543901 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 200 mg N Y N  
00781543920 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 200 mg N Y N  
16714039501 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 200 mg N Y N  
65862009620 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 200 mg N Y N  
67877087920 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 200 mg N Y N  
69292051201 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 200 mg N Y N  
69292051601 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 200 mg N Y N  
69292051650 CEFPODOXIME PROXETIL cefpodoxime proxetil TABLET 200 mg N Y N  
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