Pain Medications, Topical
PDL Reference Documents
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 & Updates |
|---|---|---|---|---|---|
| capsaicin | CAPSAICIN-HP | CREAM (G) | Y | ||
| capsaicin | ARTHRITIS PAIN RELIEVING | CREAM (G) | Y | ||
| capsaicin | CAPSAICIN | CREAM (G) | Y | ||
| capsaicin | ARTHRITIS AND MUSCLE | CREAM (G) | Y | ||
| capsaicin | ARTHRITIS PAIN RELIEF | CREAM (G) | Y | ||
| capsaicin | CAPSAICIN | CREAM (G) | Y | ||
| capsaicin | CAPSAICIN HP | CREAM (G) | Y | ||
| capsaicin | CAPZASIN-HP | CREAM (G) | Y | ||
| capsaicin | ZOSTRIX-HP | CREAM (G) | Y | ||
| capsaicin | ZOSTRIX HP FOOT | CREAM (G) | Y | ||
| capsaicin | ZOSTRIX HP | CREAM (G) | Y | ||
| capsaicin | ZOSTRIX | CREAM (G) | Y | ||
| capsaicin | MEDI-GEN | CREAM (G) | Y | ||
| capsaicin | CAPZIX | CREAM (G) | Y | ||
| capsaicin | CAPZASIN-P | CREAM (G) | Y | ||
| capsaicin | CAPSAID ES | CREAM (G) | Y | ||
| diclofenac sodium | DICLOFENAC SODIUM | GEL (GRAM) | Y | ||
| diclofenac sodium | ARTHRITIS PAIN RELIEVER | GEL (GRAM) | Y | ||
| diclofenac sodium | ARTHRITIS PAIN | GEL (GRAM) | Y | ||
| diclofenac sodium | ARTHRITIS PAIN RELIEF | GEL (GRAM) | Y | ||
| diclofenac sodium | VOLTAREN ARTHRITIS PAIN | GEL (GRAM) | Y | ||
| diclofenac sodium | MOTRIN ARTHRITIS PAIN | GEL (GRAM) | Y | ||
| diclofenac sodium | ASPERCREME ARTHRITIS PAIN | GEL (GRAM) | Y | ||
| diclofenac sodium | ARTHRITIS PAIN | GEL (GRAM) | Y | ||
| diclofenac sodium | ALEVE ARTHRITIS PAIN | GEL (GRAM) | Y | ||
| diclofenac sodium | DICLOFENAC SODIUM | GEL (GRAM) | Y | ||
| lidocaine HCl | LIDOCAINE HCL | CREAM (G) | Y | ||
| lidocaine HCl | LIDOCAINE PLUS | CREAM (G) | Y | ||
| lidocaine HCl | PAIN RELIEF | CREAM (G) | Y | ||
| lidocaine HCl | LIDOZALL PLUS | CREAM (G) | Y | ||
| lidocaine HCl | LIDOCORE | 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 HCL | JEL/PF APP | Y | ||
| lidocaine HCl | GLYDO | 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 | CAPSIMIDE | ADH. PATCH | N | ||
| capsaicin | CAPSAICIN HEAT PATCH | ADH. PATCH | N | ||
| capsaicin | CAPSAICIN | ADH. PATCH | N | ||
| capsaicin | CAPSAICIN | LOTION | N | ||
| capsaicin | ZOSTRIX | STICK (EA) | N | ||
| capsaicin/me-salicylate/menth | MEDROX | ADH. PATCH | N | ||
| capsaicin/me-salicylate/menth | MEDROX | OINT. (G) | N | ||
| capsaicin/skin cleanser | QUTENZA | KIT | N | ||
| diclofenac epolamine | DICLOFENAC EPOLAMINE | PATCH TD12 | 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 | ||
| diclofenac/kinesiology tape | LIXOFEN | KIT | N | ||
| diclofenac/menthol/camphor | DICLOGEN | KIT | N | ||
| hydrocortisone/pramoxine | EPIFOAM | FOAM | N | ||
| lidocaine | LIDOCAINE | ADH. PATCH | N | PA Document | |
| lidocaine | DERMACINRX LIDOCAN | ADH. PATCH | N | PA Document | |
| lidocaine | LIDOCAN II | ADH. PATCH | N | PA Document | |
| lidocaine | LIDOCAN III | ADH. PATCH | N | PA Document | |
| lidocaine | LIDOCAN IV | ADH. PATCH | N | PA Document | |
| lidocaine | LIDOCAN V | ADH. PATCH | N | PA Document | |
| lidocaine | ZTLIDO | ADH. PATCH | N | PA Document | |
| lidocaine | TRIDACAINE XL | ADH. PATCH | N | PA Document | |
| lidocaine | TRIDACAINE III | ADH. PATCH | N | PA Document | |
| lidocaine | TRIDACAINE II | ADH. PATCH | N | PA Document | |
| lidocaine | TRIDACAINE | ADH. PATCH | N | PA Document | |
| lidocaine | LIDODERM | ADH. PATCH | N | PA Document | |
| lidocaine | LIDOCAINE | OINT. (G) | N | ||
| lidocaine HCl | LIDAFLEX | ADH. PATCH | N | ||
| lidocaine HCl | LIDOTRAL | CREAM (G) | N | ||
| lidocaine HCl | TRILOGEL | GEL (GRAM) | N | ||
| lidocaine HCl | DERMACINRX LIDOREX | GEL (GRAM) | N | ||
| lidocaine HCl | DERMACINRX LIDOGEL | GEL (GRAM) | N | ||
| lidocaine HCl | JELCAINE STERILE | GEL (ML) | N | ||
| lidocaine HCl | LIDOCAINE | LIQD ROLON | N | ||
| lidocaine HCl | DOLOGESIC PAIN RELIEF | LIQD ROLON | N | ||
| lidocaine/hydrocortisone ac | LIDOCORT | CREAM (G) | N | ||
| lidocaine/hydrocortisone ac | LIDOCAINE-HYDROCORTISONE | CREAM (G) | N | ||
| lidocaine/kinesiology tape | XYLIDERM | KIT | N | ||
| lidocaine/prilocaine | LIDOCAINE-PRILOCAINE | KIT | N | ||
| lidocaine/tetracaine | LIDOCAINE-TETRACAINE | CREAM (G) | N | ||
| lidocaine HCl | BURN RELIEF | GEL (GRAM) | |||
| lidocaine/prilocaine | LIDOCAINE-PRILOCAINE | CREAM (G) |