Topical Nasal and Otic

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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 but eligible patients will encounter a co-pay at the pharmacy.
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
acetic acid ACETIC ACID SOLUTION    
acetic acid/aluminum acetate DOMEBORO DROPS    
antipyrine/benzocaine A/B OTIC DROPS    
benzocaine AMERICAINE DROPS    
benzocaine OTICAINE DROPS    
carbamide peroxide EAR DROPS DROPS    
carbamide peroxide EAR SYSTEM DROPS    
carbamide peroxide EAR WAX REMOVAL DROPS    
carbamide peroxide EARWAX TREATMENT DROPS DROPS    
epinephrine HCl ADRENALIN CHLORIDE SOLUTION    
fluocinolone acetonide oil FLUOCINOLONE ACETONIDE OIL DROPS    
fluocinolone acetonide oil FLAC OTIC OIL DROPS    
fluocinolone acetonide oil DERMOTIC DROPS    
hydrocortisone/acetic acid ACETASOL HC DROPS    
hydrocortisone/acetic acid HYDROCORTISONE-ACETIC ACID DROPS    
hydrocortisone/pramoxine/c-xyl CORTIC DROPS    
isopropyl alcohol in glycerin SWIM EAR DROPS    
mupirocin calcium BACTROBAN NASAL OINT. (G)    
phenylephrine/antipy/b-caine EAR-GESIC DROPS    
salt irrigation solution no.1 OCEAN COMPLETE AER W/ADAP    
sod chlor,bicarb/squeez bottle AYR PACK W/DEV    
sod chlor,sod bicarb/neti pot AYR SALINE NASAL NETIRINSE PACK W/DEV    
sodium chloride AYR SALINE DROPS    
sodium chloride BABY AYR SALINE DROPS    
sodium chloride RHINARIS GEL (GRAM)    
sodium chloride DEEP SEA SPRAY    
sodium chloride AYR SPRAY    
sodium chloride AYR SALINE SPRAY    
sodium chloride NASAL MOISTURIZING SPRAY    
sodium chloride SALINE MIST SPRAY    
sodium chloride SALINE NASAL SPRAY SPRAY    
sodium chloride SEA SOFT SPRAY    
sodium chloride OCEAN SPRAY    
sodium chloride SALINE NOSE SPRAY SPRAY    
sodium chloride RHINARIS SPRAY    
sodium chloride/aloe vera AYR SALINE GEL (GRAM)    
sodium chloride/aloe vera AYR SPRAY    
sodium chloride/sodium bicarb AYR PACKET    
sodium chloride/sodium bicarb SINUS WASH PACKET