Antibiotics - Oral Penicillins

Product Name

Penicillin V

Preferred Medicaid

Health

ABW:

Plan B:

Drug List

Choice

Wayne,

Wayne,

Macomb

Macomb

Dicloxacillin

FA

FA

FA

FA

FA

FA

PA

NF

Amoxicillin, capsules

FA

FA

FA

FA

Amoxicillin, suspension

FA

FA

PA

NF

FA

FA

FA

FA

(500mg,

(500mg,

875mg )

875mg )

Amoxicillin/potassium
clavulanate , tablets

Amoxicillin/potassium
clavulanate , suspension
and chewable
Augmentin XR
Ampicillin

Geocillin

FA

FA

PA

NF

PA

PA

PA

NF

FA

FA

FA

FA

FA

FA

PA

NF

Generics are bolded

* = Preferred Drug
*FA = Formulary
*PA = Prior Authorization required
*NF = Not on Formulary
*ST = Step Therapy
*QL = Quantity Limits

Last updated 03/2012

Last updated 03/2012