Oxazolidinones, Oral
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 00054031950 | LINEZOLID | linezolid | SUSP RECON | 100 mg/5 mL | Y | Y | |
| 31722086525 | LINEZOLID | linezolid | SUSP RECON | 100 mg/5 mL | Y | Y | |
| 59762130804 | LINEZOLID | linezolid | SUSP RECON | 100 mg/5 mL | Y | Y | |
| 60687075405 | LINEZOLID | linezolid | SUSP RECON | 100 mg/5 mL | Y | Y | |
| 00009513601 | ZYVOX | linezolid | SUSP RECON | 100 mg/5 mL | Y | Y | |
| 00009513604 | ZYVOX | linezolid | SUSP RECON | 100 mg/5 mL | Y | Y | |
| 00904655304 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 31722074920 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 31722074930 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 59762130701 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 59762130702 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 60687030911 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 60687030921 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 62135044220 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 64980056102 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 64980056103 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 67877041920 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 67877041933 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 67877041984 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 72606000111 | LINEZOLID | linezolid | TABLET | 600 mg | Y | Y | |
| 00009513802 | ZYVOX | linezolid | TABLET | 600 mg | Y | Y | |
| 67919004104 | SIVEXTRO | tedizolid phosphate | TABLET | 200 mg | N | Y | PA Document |
| 67919004105 | SIVEXTRO | tedizolid phosphate | TABLET | 200 mg | N | Y | PA Document |
| 67919004199 | SIVEXTRO | tedizolid phosphate | TABLET | 200 mg | N | Y | PA Document |