Hemorroidal Preps

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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
calamine/zinc oxide HEMORRHOIDAL SUPP.RECT    
dibucaine DIBUCAINE OINT. (G)    
hydrocortisone/lidocaine/aloe LIDOCAINE-HYDROCORTISONE GEL W/APPL    
hydrocortisone/lidocaine/aloe ANA-LEX KIT    
hydrocortisone/lidocaine/aloe LIDOCAINE-HYDROCORTISONE KIT    
hydrocortisone/pramoxine PRAMCORT CREAM/APPL    
hydrocortisone/pramoxine PROCTOFOAM-HC FOAM    
lidocaine/hydrocortisone ac LIDOCAINE-HYDROCORTISONE CREAM (G)    
lidocaine/hydrocortisone ac LIDOCAINE-HYDROCORTISONE CREAM/APPL    
lidocaine/hydrocortisone ac LIDOCAINE-HYDROCORTISONE GEL W/APPL    
lidocaine/hydrocortisone ac LIDOCAINE-HYDROCORTISONE KIT    
pe/shark liver oil/glyc/wh.pet HEMORRHOIDAL CREAM CREAM (G)    
phenyleph/mineral oil/petrolat HEMORRHOIDAL OINTMENT OINT/APPL    
phenyleph/mineral oil/petrolat MAJOR-PREP HEMORRHOIDAL OINT/APPL    
phenyleph/mineral oil/petrolat PREPARATION H OINT/APPL    
phenyleph/pramoxin/glycr/w.pet HEMORRHOIDAL CREAM CREAM (G)    
phenyleph/pramoxin/glycr/w.pet PREPARATION H CREAM (G)    
phenyleph/shark liv.oil/mo/pet HEMORRHOIDAL OINTMENT OINT. (G)    
phenyleph/shark oil/cocoa butr PREP-HEM SUPP.RECT    
phenyleph/shark oil/cocoa butr HEMORRHOIDAL SUPP.RECT    
phenylephrine HCl HEMORRHOIDAL SUPPOSITORY SUPP.RECT    
phenylephrine HCl ANU-MED SUPP.RECT    
phenylephrine HCl HEMORRHOIDAL SUPP.RECT    
phenylephrine HCl/cocoa butter HEMORRHOIDAL SUPPOSITORIES SUPP.RECT    
phenylephrine HCl/cocoa butter PREPARATION H SUPP.RECT    
phenylephrine HCl/witch hazel HEMORRHOIDAL COOLING GEL GEL (GRAM)    
phenylephrine HCl/witch hazel HEMORRHOIDAL SOOTHING GEL (GRAM)    
phenylephrine HCl/witch hazel PREPARATION H GEL (GRAM)    
pramoxine HCl PROCTOFOAM FOAM    
shark liver oil/cocoa butter HEMORRHOIDAL SUPP.RECT    
skin resp.factor/shark liv.oil HEMORRHOIDAL OINTMENT OINT/APPL    
soybean oil/starch HEMORRHOIDAL SUPP.RECT    
witch hazel PREPARATION H MED. PAD    
witch hazel PREPARATION H TOTABLES MED. PAD