Macrolides, Parenteral
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 |
|---|---|---|---|---|---|---|---|
| 25021018010 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 25021018066 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 55150017410 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 62756051240 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 62756051244 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 63323039801 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 63323039810 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 63323039814 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 63323039841 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 70095002501 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 70095002502 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 70436001982 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 70860010010 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 70860010041 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 70860012541 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 70860012566 | AZITHROMYCIN | azithromycin | VIAL | 500 mg | Y | ||
| 00069315083 | ZITHROMAX | azithromycin | VIAL | 500 mg | Y | ||
| 00069315084 | ZITHROMAX | azithromycin | VIAL | 500 mg | Y | ||
| 00409014411 | AZITHROMYCIN | azithromycin | VIAL PORT | 500 mg | Y | ||
| 00409014421 | AZITHROMYCIN | azithromycin | VIAL PORT | 500 mg | Y | ||
| 00409648201 | ERYTHROCIN LACTOBIONATE | erythromycin lactobionate | VIAL | 500 mg | Y | ||
| 00409648211 | ERYTHROCIN LACTOBIONATE | erythromycin lactobionate | VIAL | 500 mg | Y | ||
| 14789011605 | ERYTHROMYCIN LACTOBIONATE | erythromycin lactobionate | VIAL | 500 mg | Y | ||
| 14789011607 | ERYTHROMYCIN LACTOBIONATE | erythromycin lactobionate | VIAL | 500 mg | Y | ||
| 00409647644 | ERYTHROCIN LACTOBIONATE | erythromycin lactobionate | VIAL PORT | 500 mg | Y | ||
| 00409647654 | ERYTHROCIN LACTOBIONATE | erythromycin lactobionate | VIAL PORT | 500 mg | Y |