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Xxxxxx Anti-infectives Xxxxxx (Miscellaneous)
18
Name AETNA BCBSMA BMCHP FCHP HPHC HNE NHP NTWK MAHLTH THP
CHLOROQUINE PHOsPHATE PA X* DL X X X X X X X
CLINDAMyCIN oral X* X* X X X X X X X 1 X
CLINDAMyCIN vaginal X* X* X X X X X X X X
DAPsONE X* X* X X X X X X X
FOsFOMyCIN [Monurol] FE X X X X X X
HyDROXyCHLOROQUINE PA X* X X X X X X X X
LINEzOLID [zyvox] PA* X* DL PA PA PA DL X 2 X
MEBENDAzOLE X* X* X X X X X X X X
MEFLOQUINE PA* X* X X X X X X X X
METHENAMINE X* X* X X X X X X X X
METRONIDAzOLE oral X* X* X X X X X X X 3 X*
METRONIDAzOLE topical X* X* X X X X X X X X
METRONIDAzOLE vaginal X* X* X X X X X X X X
NEOMyCIN X* X* X X X X X X X X
NITAzOXANIDE [Alinia] X X* X X X PA X
NITROFURANTOIN X* X* X X X X X X X X
NITROFURANTOIN [Macrobid] FE X PA X X NC PA X
NITROFURANTOIN solution X* X* X X X X X X X
PENTAMIDINE [Nebupent] X* DL* X X X X X X
PHENAzOPyRIDINE X* X* X X X X X X X X
QUININE [Qualaquin] X DL X X PA PA X
RIFAXIMIN [Xifaxan] DL FE NC X PA X DL X DL PA
PA
TELITHROMyCIN [Ketek] FE X X X X PA X
TINIDAzOLE [Tindamax] FE NC X X X PA X
TRIMETHOPRIM X* X* X X X X X X X X
VANCOMyCIN [Vancocin] X X* X PA X X X X X X
Anti-infectives (Penicillins)
AMOXICILLIN X* X* X X X X X X X X*
AMOXICILLIN extended release X NC X NC PA NC
[Moxatag]
1 PA required for 300 mg capsule
2 PA required for oral formulations
3 PA required for 375 mg capsule and XR formulations