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    
benzocaine/menthol SORE THROAT LOZENGE LOZENGE    
benzocaine/menthol LOZENGES LOZENGE    
benzocaine/menthol CEPACOL SORE THROAT LOZENGE    
benzocaine/resorcinol VAGINAL ITCH CREAM CREAM (G)    
benzocaine/resorcinol VAGICAINE CREAM (G)    
benzocaine/triclosan FIRST AID SPRAY    
bupivacaine HCl SENSORCAINE VIAL    
bupivacaine HCl MARCAINE VIAL    
bupivacaine HCl BUPIVACAINE HCL VIAL    
Bupivacaine HCl/Dex-Water/PF SENSORCAINE WITH DEXTROSE AMPUL    
Bupivacaine HCl/Dex-Water/PF MARCAINE SPINAL AMPUL    
Bupivacaine HCl/Dex-Water/PF BUPIVACAINE-DEXTROSE AMPUL    
bupivacaine HCl/epinephrine MARCAINE-EPINEPHRINE AMPUL    
bupivacaine HCl/epinephrine BUPIVACAINE HCL-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine MARCAINE-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine SENSORCAINE-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine bi BUPIVACAINE HCL-EPINEPHRINE CARTRIDGE    
bupivacaine HCl/epinephrine/PF BUPIVACAINE HCL-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine/PF MARCAINE-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine/PF SENSORCAINE-MPF EPINEPHRINE VIAL    
bupivacaine HCl/PF SENSORCAINE-MPF AMPUL    
bupivacaine HCl/PF BUPIVACAINE HCL AMPUL    
bupivacaine HCl/PF SENSORCAINE-MPF VIAL    
bupivacaine HCl/PF BUPIVACAINE HCL VIAL    
bupivacaine HCl/PF MARCAINE 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 LIDOCAINE HCL SOLUTION    
lidocaine HCl LIDOCAINE HCL VISCOUS SOLUTION    
lidocaine HCl PRE-ATTACHED LTA KIT SOLUTION    
lidocaine HCl LIDOCAINE HCL SYRINGE    
lidocaine HCl LIDOCAINE HCL VIAL    
lidocaine HCl XYLOCAINE 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 LIDOCAINE HCL-EPINEPHRINE AMPUL    
lidocaine HCl/epinephrine/PF XYLOCAINE-MPF WITH 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 LIDOCAINE HCL AMPUL    
lidocaine HCl/PF XYLOCAINE-MPF 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 SPRAY    
lidocaine/aloe vera BURN RELIEF W-ALOE 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 EMPRICAINE KIT    
lidocaine/prilocaine DERMACINRX PRIZOPAK KIT    
lidocaine/prilocaine LIDOCAINE-PRILOCAINE KIT    
lidocaine/prilocaine-0.9% NaCl IV INFUSION CPI KIT    
lidocaine/tetracaine LIDOCAINE-TETRACAINE CREAM (G)    
lidocaine/tetracaine PLIAGLIS CREAM (G)    
lidocaine/tetracaine SYNERA M.HT PATCH    
lidocaine/transparent dressing LIDOCAINE KIT    
mepivacaine HCl POLOCAINE VIAL    
mepivacaine HCl CARBOCAINE VIAL    
mepivacaine HCl/PF MEPIVACAINE HCL CARTRIDGE    
mepivacaine HCl/PF CARBOCAINE VIAL    
mepivacaine HCl/PF POLOCAINE-MPF VIAL    
phenazopyridine HCl URINARY PAIN RELIEF TABLET    
phenazopyridine HCl PYRIDIUM TABLET    
phenazopyridine HCl PHENAZOPYRIDINE HCL TABLET    
phenazopyridine HCl PRODIUM TABLET    
phenol PHENASEPTIC SPRAY    
phenol SORE THROAT SPRAY SPRAY    
phenol/sodium phenolate MOUTHWASH/GARGLE SPRAY    
phenol/sodium phenolate SORE THROAT SPRAY SPRAY    
phenol/sodium phenolate THROAT SPRAY 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