Antibiotics, Vaginal

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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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00009344801 CLEOCIN clindamycin phosphate CREAM/APPL 2 % Y Y N  
00168027740 CLINDAMYCIN PHOSPHATE clindamycin phosphate CREAM/APPL 2 % Y Y N  
59762500901 CLINDAMYCIN PHOSPHATE clindamycin phosphate CREAM/APPL 2 % Y Y N  
45802004201 CLINDESSE clindamycin phosphate CRM ER (G) 2 % N Y N  
78206018901 XACIATO clindamycin phosphate GEL W/APPL 2 % N Y N  
78206018999 XACIATO clindamycin phosphate GEL W/APPL 2 % N Y N  
00009766701 CLEOCIN clindamycin phosphate SUPP.VAG 100 mg Y Y N  
00009766705 CLEOCIN clindamycin phosphate SUPP.VAG 100 mg Y Y N  
00713057571 METRONIDAZOLE metronidazole GEL W/APPL 0.75 % Y Y N  
16714055701 METRONIDAZOLE metronidazole GEL W/APPL 0.75 % Y Y N  
21922003923 METRONIDAZOLE metronidazole GEL W/APPL 0.75 % Y Y N  
45802013970 METRONIDAZOLE metronidazole GEL W/APPL 0.75 % Y Y N  
68462018449 METRONIDAZOLE metronidazole GEL W/APPL 0.75 % Y Y N  
71656006770 METRONIDAZOLE metronidazole GEL W/APPL 0.75 % Y Y N  
73473030370 METRONIDAZOLE metronidazole GEL W/APPL 0.75 % Y Y N  
00245086070 VANDAZOLE metronidazole GEL W/APPL 0.75 % Y Y N  
21922004641 METRONIDAZOLE metronidazole GEL W/APPL 1.3 % N Y N  
00642746605 NUVESSA metronidazole GEL W/APPL 1.3 % N Y N  
00642746606 NUVESSA metronidazole GEL W/APPL 1.3 % N Y N  
27437005101 SOLOSEC secnidazole GRANDR PKT 2 gram N Y N  
69751040001 SOLOSEC secnidazole GRANDR PKT 2 gram N Y N  
42799020701 TINIDAZOLE tinidazole TABLET 250 mg N Y N  
62135083420 TINIDAZOLE tinidazole TABLET 250 mg N Y N  
64980042602 TINIDAZOLE tinidazole TABLET 250 mg N Y N  
42799020801 TINIDAZOLE tinidazole TABLET 500 mg N Y N  
44523045012 TINIDAZOLE tinidazole TABLET 500 mg N Y N  
44523045020 TINIDAZOLE tinidazole TABLET 500 mg N Y N  
62135083520 TINIDAZOLE tinidazole TABLET 500 mg N Y N  
64980042712 TINIDAZOLE tinidazole TABLET 500 mg N Y N  
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