Anesthetics Local Topical

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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
benzocaine BENZOCAINE CREAM (G)    
benzocaine ZILACTIN-B GEL (GRAM)    
benzocaine ANBESOL GEL (GRAM)    
benzocaine OUTGRO LIQUID    
benzocaine ANBESOL LIQUID    
benzocaine/aloe vera DERMACAINE W/ALOE CREAM (G)    
benzocaine/benzethon Cl LANACANE FIRST AID AEROSOL    
benzocaine/menth/cetylpyrd Cl ORASEP SPRAY    
benzocaine/menthol SORE THROAT LOZENGE LOZENGE    
benzocaine/menthol SORE THROAT LOZENGE    
benzocaine/menthol CEPACOL SORE THROAT LOZENGE    
benzocaine/menthol LOZENGES LOZENGE    
benzocaine/resorcinol VAGINAL ITCH CREAM CREAM (G)    
benzocaine/resorcinol VAGICAINE CREAM (G)    
benzocaine/triclosan FIRST AID SPRAY    
bupivacaine HCl MARCAINE VIAL    
bupivacaine HCl BUPIVACAINE HCL VIAL    
bupivacaine HCl SENSORCAINE VIAL    
bupivacaine HCl in dextrose/PF MARCAINE SPINAL AMPUL    
bupivacaine HCl in dextrose/PF BUPIVACAINE-DEXTROSE AMPUL    
bupivacaine HCl in dextrose/PF SENSORCAINE WITH DEXTROSE AMPUL    
bupivacaine HCl/epinephrine MARCAINE-EPINEPHRINE AMPUL    
bupivacaine HCl/epinephrine SENSORCAINE-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine MARCAINE-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine BUPIVACAINE HCL-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine bi BUPIVACAINE HCL-EPINEPHRINE CARTRIDGE    
bupivacaine HCl/epinephrine/PF MARCAINE-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine/PF SENSORCAINE-MPF EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine/PF BUPIVACAINE HCL-EPINEPHRINE VIAL    
bupivacaine HCl/PF SENSORCAINE-MPF AMPUL    
bupivacaine HCl/PF BUPIVACAINE HCL AMPUL    
bupivacaine HCl/PF SENSORCAINE-MPF VIAL    
bupivacaine HCl/PF MARCAINE VIAL    
bupivacaine HCl/PF BUPIVACAINE HCL VIAL    
chloroprocaine HCl NESACAINE VIAL    
chloroprocaine HCl/PF NESACAINE-MPF VIAL    
chloroprocaine HCl/PF CHLOROPROCAINE HCL VIAL    
chlorothymol/b-caine/resor/iod DERMACAINE CREAM (G)    
cocaine HCl COCAINE HCL SOLUTION    
dibucaine DIBUCAINE OINT. (G)    
hydrocortisone/pramoxine EPIFOAM FOAM    
lidocaine HCl LIDOTRAL CREAM (G)    
lidocaine HCl LIDOCAINE HCL CREAM (G)    
lidocaine HCl LIDOCAINE HCL JEL/PF APP    
lidocaine HCl GLYDO JEL/PF APP    
lidocaine HCl LIDOCAINE HCL JELLY(ML)    
lidocaine HCl LIDOZION LOTION    
lidocaine HCl ZINGO PEN INJCTR    
lidocaine HCl PRE-ATTACHED LTA KIT SOLUTION    
lidocaine HCl LIDOCAINE HCL SOLUTION    
lidocaine HCl LIDOCAINE HCL VISCOUS SOLUTION    
lidocaine HCl LIDOCAINE HCL SYRINGE    
lidocaine HCl XYLOCAINE VIAL    
lidocaine HCl LIDOCAINE HCL VIAL    
lidocaine HCl/dextrose 7.5%/PF LIDOCAINE HCL IN 7.5% DEXTROSE AMPUL    
lidocaine HCl/epinephrine LIDOCAINE HCL-EPINEPHRINE AMPUL    
lidocaine HCl/epinephrine LIDOCAINE HCL-EPINEPHRINE VIAL    
lidocaine HCl/epinephrine XYLOCAINE WITH EPINEPHRINE VIAL    
lidocaine HCl/epinephrine bit LIDOCAINE-EPINEPHRINE CARTRIDGE    
lidocaine HCl/epinephrine/PF XYLOCAINE-MPF WITH EPINEPHRINE AMPUL    
lidocaine HCl/epinephrine/PF LIDOCAINE HCL-EPINEPHRINE AMPUL    
lidocaine HCl/epinephrine/PF LIDOCAINE HCL W/EPINEPHRINE AMPUL    
lidocaine HCl/epinephrine/PF XYLOCAINE-MPF WITH EPINEPHRINE VIAL    
lidocaine HCl/epinephrine/PF XYLOCAINE WITH EPINEPHRINE VIAL    
lidocaine HCl/PF XYLOCAINE-MPF AMPUL    
lidocaine HCl/PF LIDOCAINE HCL AMPUL    
lidocaine HCl/PF XYLOCAINE-MPF AMPUL LUER    
lidocaine HCl/PF LIDOCAINE HCL VIAL    
lidocaine HCl/PF XYLOCAINE-MPF VIAL    
lidocaine/aloe vera ALOE VERA-LIDOCAINE GEL (GRAM)    
lidocaine/aloe vera BURN RELIEF W-ALOE SPRAY    
lidocaine/aloe vera BURN RELIEF SPRAY    
lidocaine/benzalkonium/alcohol FIRST AID ANTISEPTIC SOLUTION    
lidocaine/dimethicone DERMACINRX ZRM PAK KIT PAT-CR    
lidocaine/emollient cmb no.102 DERMACINRX PHN PAK KIT PAT-CR    
lidocaine/hydrocortisone ac LIDOCAINE-HYDROCORTISONE CREAM (G)    
lidocaine/prilocaine LIDOCAINE-PRILOCAINE CREAM (G)    
lidocaine/prilocaine DERMACINRX PRIZOPAK KIT    
lidocaine/prilocaine DERMACINRX EMPRICAINE KIT    
lidocaine/prilocaine LIDOCAINE-PRILOCAINE KIT    
lidocaine/prilocaine-0.9% NaCl IV INFUSION CPI KIT    
lidocaine/tetracaine PLIAGLIS CREAM (G)    
lidocaine/tetracaine LIDOCAINE-TETRACAINE CREAM (G)    
lidocaine/tetracaine SYNERA M.HT PATCH    
lidocaine/transparent dressing LIDOCAINE KIT    
mepivacaine HCl CARBOCAINE VIAL    
mepivacaine HCl POLOCAINE VIAL    
mepivacaine HCl/PF MEPIVACAINE HCL CARTRIDGE    
mepivacaine HCl/PF CARBOCAINE VIAL    
mepivacaine HCl/PF POLOCAINE-MPF VIAL    
phenazopyridine HCl PYRIDIUM TABLET    
phenazopyridine HCl PRODIUM TABLET    
phenazopyridine HCl URINARY PAIN RELIEF TABLET    
phenazopyridine HCl PHENAZOPYRIDINE HCL TABLET    
phenol PHENASEPTIC SPRAY    
phenol SORE THROAT SPRAY SPRAY    
phenol/sodium phenolate THROAT SPRAY SPRAY    
phenol/sodium phenolate SORE THROAT SPRAY SPRAY    
phenol/sodium phenolate MOUTHWASH/GARGLE SPRAY    
pramoxine HCl SARNA SENSITIVE LOTION    
prilocaine HCl CITANEST AMPUL    
prilocaine HCl CITANEST VIAL    
ropivacaine HCl/PF NAROPIN AMPUL    
ropivacaine HCl/PF NAROPIN INFUS. BTL    
ropivacaine HCl/PF ROPIVACAINE HCL INFUS. BTL    
ropivacaine HCl/PF NAROPIN PLAST. BAG    
ropivacaine HCl/PF NAROPIN VIAL    
ropivacaine HCl/PF ROPIVACAINE HCL VIAL    
t-caine/menth/zinc ox/ichtham BURN OINTMENT OINT. (G)    
tetracaine PONTOCAINE OINT. (G)    
tetracaine HCl/PF TETRACAINE HCL AMPUL