Pain Medications, Topical

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Drug Use Review 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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
capsaicin ARTHRITIS PAIN RELIEVING CREAM (G) Y    
capsaicin CAPSAICIN CREAM (G) Y    
capsaicin CAPSAICIN-HP CREAM (G) Y    
capsaicin ZOSTRIX-HP CREAM (G) Y    
capsaicin ZOSTRIX HP CREAM (G) Y    
capsaicin ZOSTRIX HP FOOT CREAM (G) Y    
capsaicin CAPZIX CREAM (G) Y    
capsaicin ZOSTRIX CREAM (G) Y    
capsaicin MEDI-GEN CREAM (G) Y    
capsaicin CAPZASIN-P CREAM (G) Y    
capsaicin CAPSAICIN HP CREAM (G) Y    
capsaicin CAPSAICIN CREAM (G) Y    
capsaicin ARTHRITIS PAIN RELIEF CREAM (G) Y    
capsaicin ARTHRITIS AND MUSCLE CREAM (G) Y    
capsaicin CAPZASIN-HP CREAM (G) Y    
diclofenac sodium ARTHRITIS PAIN GEL (GRAM) Y    
diclofenac sodium ARTHRITIS PAIN RELIEVER GEL (GRAM) Y    
diclofenac sodium DICLOFENAC SODIUM GEL (GRAM) Y    
diclofenac sodium VOLTAREN ARTHRITIS PAIN GEL (GRAM) Y    
diclofenac sodium MOTRIN ARTHRITIS PAIN GEL (GRAM) Y    
diclofenac sodium DICLOFENAC SODIUM GEL (GRAM) Y    
diclofenac sodium ASPERCREME ARTHRITIS PAIN GEL (GRAM) Y    
diclofenac sodium ARTHRITIS PAIN RELIEF GEL (GRAM) Y    
diclofenac sodium ARTHRITIS PAIN GEL (GRAM) Y    
diclofenac sodium ALEVE ARTHRITIS PAIN GEL (GRAM) Y    
lidocaine HCl LIDOCAINE HCL CREAM (G) Y    
lidocaine HCl LIDOCAINE HCL CREAM (G) Y    
lidocaine HCl GOLD BOND MEDICATED PAIN-ITCH CREAM (G) Y    
lidocaine HCl ASPERCREME LIDOCAINE CREAM (G) Y    
lidocaine HCl LIDOCAINE PLUS CREAM (G) Y    
lidocaine HCl PAIN RELIEF CREAM (G) Y    
lidocaine HCl GLYDO JEL/PF APP Y    
lidocaine HCl LIDOCAINE HCL JEL/PF APP Y    
lidocaine HCl LIDOCAINE HCL VISCOUS SOLUTION Y    
lidocaine HCl LIDOCAINE HCL SOLUTION Y    
lidocaine/prilocaine LIDOCAINE-PRILOCAINE CREAM (G) Y    
capsaicin CAPSAICIN ADH. PATCH N    
capsaicin CAPSAICIN HEAT PATCH ADH. PATCH N    
capsaicin CAPSIMIDE ADH. PATCH N    
capsaicin CAPSAICIN LOTION N    
capsaicin ZOSTRIX STICK (EA) N    
capsaicin/skin cleanser QUTENZA KIT N    
diclofenac epolamine FLECTOR PATCH TD12 N    
diclofenac epolamine DICLOFENAC EPOLAMINE PATCH TD12 N    
diclofenac epolamine LICART PATCH TD24 N    
diclofenac sodium DICLOFENAC SODIUM DROPS N    
diclofenac sodium DICLOFENAC SODIUM GEL (GRAM) N    
diclofenac sodium DICLOFENAC SODIUM SOL MD PMP N    
diclofenac sodium PENNSAID SOL MD PMP N    
diclofenac sodium PENNSAID SOLN PK(G) N    
hydrocortisone/pramoxine EPIFOAM FOAM N    
lidocaine LIDOCAN II ADH. PATCH N PA Document  
lidocaine LIDODERM ADH. PATCH N PA Document  
lidocaine ZTLIDO ADH. PATCH N PA Document  
lidocaine LIDOCAN III ADH. PATCH N PA Document  
lidocaine LIDOCAINE ADH. PATCH N PA Document  
lidocaine DERMACINRX LIDOCAN ADH. PATCH N PA Document  
lidocaine LIDOCAINE OINT. (G) N    
lidocaine HCl LIDAFLEX ADH. PATCH N    
lidocaine HCl LIDOTRAL CREAM (G) N    
lidocaine HCl DERMACINRX LIDOGEL GEL (GRAM) N    
lidocaine HCl DERMACINRX LIDOREX GEL (GRAM) N    
lidocaine/hydrocortisone ac LIDOCAINE-HYDROCORTISONE CREAM (G) N    
lidocaine/hydrocortisone ac LIDOCORT CREAM (G) N    
lidocaine/kinesiology tape XYLIDERM KIT N    
lidocaine/prilocaine LIDOCAINE-PRILOCAINE KIT N    
lidocaine HCl BURN RELIEF GEL (GRAM)    
lidocaine HCl DOLOGESIC PAIN RELIEF LIQD ROLON    
lidocaine HCl LIDOCAINE LIQD ROLON