Antifungals, Parenteral

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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
39822105505 AMPHOTERICIN B amphotericin B VIAL 50 mg Y N  
57665010141 ABELCET amphotericin B lipid complex VIAL 5 mg/mL Y N  
00469305130 AMBISOME amphotericin B liposome VIAL 50 mg Y N  
23155059431 AMPHOTERICIN B LIPOSOME amphotericin B liposome VIAL 50 mg Y N  
55150036501 AMPHOTERICIN B LIPOSOME amphotericin B liposome VIAL 50 mg Y N  
62756023301 AMPHOTERICIN B LIPOSOME amphotericin B liposome VIAL 50 mg Y N  
62756095401 AMPHOTERICIN B LIPOSOME amphotericin B liposome VIAL 50 mg Y N  
67457092650 AMPHOTERICIN B LIPOSOME amphotericin B liposome VIAL 50 mg Y N  
00049011628 ERAXIS anidulafungin VIAL 100 mg Y N  
00049224201 ERAXIS anidulafungin VIAL 100 mg Y N  
00049011428 ERAXIS anidulafungin VIAL 50 mg Y N  
00781342101 CASPOFUNGIN ACETATE caspofungin acetate VIAL 50 mg Y N  
00781342194 CASPOFUNGIN ACETATE caspofungin acetate VIAL 50 mg Y N  
25021019410 CASPOFUNGIN ACETATE caspofungin acetate VIAL 50 mg Y N  
59923061450 CASPOFUNGIN ACETATE caspofungin acetate VIAL 50 mg Y N  
63323035601 CASPOFUNGIN ACETATE caspofungin acetate VIAL 50 mg Y N  
63323035610 CASPOFUNGIN ACETATE caspofungin acetate VIAL 50 mg Y N  
72266010601 CASPOFUNGIN ACETATE caspofungin acetate VIAL 50 mg Y N  
00006382310 CANCIDAS caspofungin acetate VIAL 70 mg Y N  
00781342301 CASPOFUNGIN ACETATE caspofungin acetate VIAL 70 mg Y N  
00781342394 CASPOFUNGIN ACETATE caspofungin acetate VIAL 70 mg Y N  
25021019510 CASPOFUNGIN ACETATE caspofungin acetate VIAL 70 mg Y N  
59923061370 CASPOFUNGIN ACETATE caspofungin acetate VIAL 70 mg Y N  
63323035801 CASPOFUNGIN ACETATE caspofungin acetate VIAL 70 mg Y N  
63323035810 CASPOFUNGIN ACETATE caspofungin acetate VIAL 70 mg Y N  
72266010701 CASPOFUNGIN ACETATE caspofungin acetate VIAL 70 mg Y N  
00409468827 FLUCONAZOLE IN SALINE fluconazole in NaCL,iso-osm PIGGYBACK 200 mg/100 mL Y N  
00338604648 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 200 mg/100 mL Y N  
00409343501 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 200 mg/100 mL Y N  
00409343524 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 200 mg/100 mL Y N  
00409468818 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 200 mg/100 mL Y N  
00409468822 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 200 mg/100 mL Y N  
00409468829 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 200 mg/100 mL Y N  
25021018466 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 200 mg/100 mL Y N  
25021018482 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 200 mg/100 mL Y N  
00409468833 FLUCONAZOLE IN SALINE fluconazole in NaCL,iso-osm PIGGYBACK 400 mg/200 mL Y N  
00338604537 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 400 mg/200 mL Y N  
00409432101 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 400 mg/200 mL Y N  
00409432124 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 400 mg/200 mL Y N  
00409468812 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 400 mg/200 mL Y N  
00409468816 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 400 mg/200 mL Y N  
25021018467 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 400 mg/200 mL Y N  
25021018487 FLUCONAZOLE-NACL fluconazole in NaCL,iso-osm PIGGYBACK 400 mg/200 mL Y N  
00469042001 CRESEMBA isavuconazonium sulfate VIAL 372 mg N Y N  
00338905301 MICAFUNGIN-0.9% NACL micafungin in 0.9 % sodium chl PIGGYBACK 100 mg/100 mL Y N  
00338905312 MICAFUNGIN-0.9% NACL micafungin in 0.9 % sodium chl PIGGYBACK 100 mg/100 mL Y N  
00338905501 MICAFUNGIN-0.9% NACL micafungin in 0.9 % sodium chl PIGGYBACK 150 mg/150 mL Y N  
00338905510 MICAFUNGIN-0.9% NACL micafungin in 0.9 % sodium chl PIGGYBACK 150 mg/150 mL Y N  
00338905101 MICAFUNGIN-0.9% NACL micafungin in 0.9 % sodium chl PIGGYBACK 50 mg/50 mL Y N  
00338905112 MICAFUNGIN-0.9% NACL micafungin in 0.9 % sodium chl PIGGYBACK 50 mg/50 mL Y N  
00143936201 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
16714030101 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
16714030110 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
25021019110 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
25021019111 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
42023023001 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
42023023010 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
63323072901 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
63323072902 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
63323072910 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
63323072912 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
68462077201 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
68462077210 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
70377007691 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
70594003701 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
70710172501 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
70710172506 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
71288002910 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
71288002911 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
71288002912 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
72572042701 MICAFUNGIN micafungin sodium VIAL 100 mg Y N  
00469321110 MYCAMINE micafungin sodium VIAL 100 mg Y N  
00143936101 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
16714016401 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
16714016410 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
25021019010 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
25021019011 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
42023022901 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
42023022910 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
63323072801 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
63323072810 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
68462077101 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
68462077110 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
70377007591 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
70594003601 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
70710172401 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
70710172406 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
71288002810 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
71288002811 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
71288002812 MICAFUNGIN micafungin sodium VIAL 50 mg Y N  
00469325010 MYCAMINE micafungin sodium VIAL 50 mg Y N  
00085433101 NOXAFIL posaconazole VIAL 300 mg/16.7 mL Y N  
31722037031 POSACONAZOLE posaconazole VIAL 300 mg/16.7 mL Y N  
42023019501 POSACONAZOLE posaconazole VIAL 300 mg/16.7 mL Y N  
55150038801 POSACONAZOLE posaconazole VIAL 300 mg/16.7 mL Y N  
63323068517 POSACONAZOLE posaconazole VIAL 300 mg/16.7 mL Y N  
67457066520 POSACONAZOLE posaconazole VIAL 300 mg/16.7 mL Y N  
68462090401 POSACONAZOLE posaconazole VIAL 300 mg/16.7 mL Y N  
68462091101 POSACONAZOLE posaconazole VIAL 300 mg/16.7 mL Y N  
70842024001 REZZAYO rezafungin acetate VIAL 200 mg Y N Pharmacy PA
00049319001 VFEND IV voriconazole VIAL 200 mg Y N  
00049319028 VFEND IV voriconazole VIAL 200 mg Y N  
00049419001 VFEND IV voriconazole VIAL 200 mg Y N  
00781341694 VORICONAZOLE voriconazole VIAL 200 mg Y N  
31722022431 VORICONAZOLE voriconazole VIAL 200 mg Y N  
65219019030 VORICONAZOLE voriconazole VIAL 200 mg Y N  
70436002980 VORICONAZOLE voriconazole VIAL 200 mg Y N  
71288002730 VORICONAZOLE voriconazole VIAL 200 mg Y N  
72266013101 VORICONAZOLE voriconazole VIAL 200 mg Y N  
72572087501 VORICONAZOLE voriconazole VIAL 200 mg Y N  
70594006701 VORICONAZOLE (HPBCD) voriconazole/HPBCD VIAL 200 mg Y N  
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