Oral Analgesics, Other

← Back to Class List

PDL Reference Documents

Newsletters

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.

Alternate detailed view >

Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
acetaminophen MAPAP CAPSULE Y    
acetaminophen ACETAMINOPHEN CAPSULE Y    
acetaminophen TYLOPHEN CAPSULE Y    
acetaminophen TYLENOL CAPSULE Y    
acetaminophen MARDOL DROPS Y    
acetaminophen INFANT'S PAIN RELIEVER DROPS Y    
acetaminophen INFANTS PAIN RELIEVER DROPS Y    
acetaminophen INFANT'S NON-ASPIRIN DROPS Y    
acetaminophen INFANTS ASPIRIN FREE DROPS Y    
acetaminophen INFANT DROPS DROPS Y    
acetaminophen INFANT DROPS DROPS Y    
acetaminophen INFANT'S NON-ASPIRIN DROPS Y    
acetaminophen ACETAMINOPHEN DROPS Y    
acetaminophen NON-ASPIRIN DROPS Y    
acetaminophen PANADOL CHILDREN'S DROPS Y    
acetaminophen TYLENOL FOR CHILDREN DROPS Y    
acetaminophen CHILD'S PAIN RELIEVER W/O ASA ELIXIR Y    
acetaminophen CHILDREN'S PAIN RELIEVER ELIXIR Y    
acetaminophen CHILDREN'S PAIN RELIEF ELIXIR Y    
acetaminophen CHILDREN'S NON-ASPIRIN ELIXIR Y    
acetaminophen CHILDREN'S APAP ELIXIR Y    
acetaminophen APRA ELIXIR Y    
acetaminophen MARDOL ELIXIR Y    
acetaminophen KOMAPHEN ELIXIR Y    
acetaminophen DOLONO ELIXIR Y    
acetaminophen ACETAMINOPHEN ELIXIR Y    
acetaminophen ACETAMINOPHEN ELIXIR Y    
acetaminophen NON-ASPIRIN PAIN RELIEF ELIXIR Y    
acetaminophen NON-ASPIRIN ELIXIR Y    
acetaminophen PANADOL CHILDREN'S ELIXIR Y    
acetaminophen LITTLE REMEDIES FEVER-PAIN LIQUID Y    
acetaminophen KOSHER CARE LIQUID Y    
acetaminophen CHILDREN'S ACETAMINOPHEN LIQUID Y    
acetaminophen CHILDREN'S PAIN AND FEVER LIQUID Y    
acetaminophen MAPAP LIQUID Y    
acetaminophen M-PAP LIQUID Y    
acetaminophen REDUTEMP LIQUID Y    
acetaminophen ED-APAP LIQUID Y    
acetaminophen ACETAMINOPHEN LIQUID Y    
acetaminophen ACETAMINOPHEN LIQUID Y    
acetaminophen MAXRELIEF JUNIOR LIQUID Y    
acetaminophen PAIN RELIEVER ADULT LIQUID Y    
acetaminophen PAIN RELIEF ADULT LIQUID Y    
acetaminophen NON-ASPIRIN LIQUID Y    
acetaminophen M-PAP LIQUID Y    
acetaminophen PAIN RELIEF LIQUID Y    
acetaminophen TYLENOL SORE THROAT LIQUID Y    
acetaminophen CHILDREN'S TYLENOL ORAL SUSP Y    
acetaminophen CHILDREN'S PAIN-FEVER ORAL SUSP Y    
acetaminophen CHILDREN'S PAIN RELIEVER ORAL SUSP Y    
acetaminophen CHILDREN'S PAIN RELIEF ORAL SUSP Y    
acetaminophen FEVER REDUCER-PAIN RELIEVER ORAL SUSP Y    
acetaminophen CHILDREN'S ACETAMINOPHEN ORAL SUSP Y    
acetaminophen CHILD FEVER REDUCER-PAIN RELVR ORAL SUSP Y    
acetaminophen BETATEMP ORAL SUSP Y    
acetaminophen CHILDREN'S NON-ASPIRIN ORAL SUSP Y    
acetaminophen INFANTS' PAIN-FEVER ORAL SUSP Y    
acetaminophen LITTLE REMEDIES FEVER-PAIN ORAL SUSP Y    
acetaminophen KINDERMED KIDS PAIN-FEVER ORAL SUSP Y    
acetaminophen KINDERMED INFANTS PAIN-FEVER ORAL SUSP Y    
acetaminophen INFANTS' TYLENOL ORAL SUSP Y    
acetaminophen INFANTS' PAIN RELIEVER ORAL SUSP Y    
acetaminophen INFANTS' FEVER-PAIN RELIEVER ORAL SUSP Y    
acetaminophen INFANTS' ACETAMINOPHEN ORAL SUSP Y    
acetaminophen INFANT PAIN-FEVER ORAL SUSP Y    
acetaminophen INFANT PAIN RELIEF ORAL SUSP Y    
acetaminophen INFANT FEVER-PAIN RELIEVER ORAL SUSP Y    
acetaminophen INFANTS' ACETAMINOPHEN ORAL SUSP Y    
acetaminophen CHILDREN'S ACETAMINOPHEN ORAL SUSP Y    
acetaminophen CHILDREN'S PAIN RELIEF ORAL SUSP Y    
acetaminophen CHILDREN'S PAIN-FEVER ORAL SUSP Y    
acetaminophen INFANTS' PAIN-FEVER ORAL SUSP Y    
acetaminophen MAPAP CHILDREN'S ORAL SUSP Y    
acetaminophen ACETAMINOPHEN ORAL SUSP Y    
acetaminophen MAXRELIEF JUNIOR ORAL SUSP Y    
acetaminophen NON-ASPIRIN ORAL SUSP Y    
acetaminophen CHILDREN'S TYLENOL TAB CHEW Y    
acetaminophen CHILDREN'S PAIN-FEVER TAB CHEW Y    
acetaminophen CHILDREN'S PAIN RELIEF TAB CHEW Y    
acetaminophen CHILDREN'S NON-ASPIRIN TAB CHEW Y    
acetaminophen CHILDREN'S APAP TAB CHEW Y    
acetaminophen CHILDREN'S ACETAMINOPHEN TAB CHEW Y    
acetaminophen CHILDREN'S ACETAMINOPHEN TAB CHEW Y    
acetaminophen CHILDREN'S MAPAP TAB CHEW Y    
acetaminophen CHILDREN'S PAIN RELIEF TAB CHEW Y    
acetaminophen CHILDREN'S PAIN-FEVER RELIEF TAB CHEW Y    
acetaminophen PAIN RELIEVER JUNIOR STRENGTH TAB CHEW Y    
acetaminophen ACETAMINOPHEN TAB CHEW Y    
acetaminophen PAIN RELIEVER W-O ASPIRIN TAB CHEW Y    
acetaminophen PAIN RELIEVER W/O ASA TAB CHEW Y    
acetaminophen PAIN RELIEVER JUNIOR STRENGTH TAB CHEW Y    
acetaminophen NON-ASPIRIN PAIN RELIEF JR TAB CHEW Y    
acetaminophen NON-ASPIRIN PAIN RELIEF TAB CHEW Y    
acetaminophen NON-ASPIRIN JR STRENGTH TAB CHEW Y    
acetaminophen NON-ASPIRIN TAB CHEW Y    
acetaminophen CHILDREN'S EASY-MELTS TAB RAPDIS Y    
acetaminophen JUNIOR PAIN RELIEVER TAB RAPDIS Y    
acetaminophen JR PAIN & FEVER TAB RAPDIS Y    
acetaminophen ACETAMINOPHEN TAB RAPDIS Y    
acetaminophen APAP TABLET Y    
acetaminophen ATHENOL TABLET Y    
acetaminophen TYLENOL EXTRA STRENGTH ARTHRIT TABLET Y    
acetaminophen MASOPHEN TABLET Y    
acetaminophen MARDOL TABLET Y    
acetaminophen MAPAP TABLET Y    
acetaminophen AMINOFEN TABLET Y    
acetaminophen APHEN TABLET Y    
acetaminophen PAIN RELIEF TABLET Y    
acetaminophen PAIN RELIEF EXTRA STRENGTH TABLET Y    
acetaminophen PAIN RELIEVER TABLET Y    
acetaminophen ACETAMINOPHEN EXTRA STRENGTH TABLET Y    
acetaminophen ACETAMINOPHEN TABLET Y    
acetaminophen ACETAMINOPHEN TABLET Y    
acetaminophen MEDI-TABS TABLET Y    
acetaminophen NON-ASPIRIN PAIN RELIEF TABLET Y    
acetaminophen PAIN RELIEVER W/O ASPIRIN TABLET Y    
acetaminophen PAIN RELIEVER NON-ASA EX STR TABLET Y    
acetaminophen PAIN RELIEVER TABLET Y    
acetaminophen PAIN RELIEF W/O ASPIRIN TABLET Y    
acetaminophen PAIN RELIEF EXTRA STRENGTH TABLET Y    
acetaminophen PAIN RELIEF TABLET Y    
acetaminophen PHARBETOL TABLET Y    
acetaminophen NON-ASPIRIN EXTRA STRENGTH TABLET Y    
acetaminophen NON-ASPIRIN TABLET Y    
acetaminophen MEDI-TABS EXTRA STRENGTH TABLET Y    
acetaminophen TYLENOL EXTRA STRENGTH TABLET Y    
acetaminophen TYLENOL TABLET Y    
acetaminophen TACTINAL TABLET Y    
acetaminophen SHAKE THAT ACHE TABLET Y    
acetaminophen TYLENOL ARTHRITIS TABLET ER Y    
acetaminophen ARTHRITIS PAIN RELIEVER TABLET ER Y    
acetaminophen ARTHRITIS PAIN RELIEF TABLET ER Y    
acetaminophen ARTHRITIS PAIN TABLET ER Y    
acetaminophen EXTENDED PAIN RELIEF TABLET ER Y    
acetaminophen ARTHRITIS PAIN RELIEVER TABLET ER Y    
acetaminophen ACETAMINOPHEN ER TABLET ER Y    
acetaminophen 8 HOUR ACETAMINOPHEN TABLET ER Y    
acetaminophen ACETAMINOPHEN ER TABLET ER Y    
acetaminophen 8HR MUSCLE ACHES-PAIN TABLET ER Y    
acetaminophen 8HR ARTHRITIS PAIN RELIEF TABLET ER Y    
acetaminophen ARTHRITIS PAIN RELIEF TABLET ER Y    
acetaminophen 8 HOUR PAIN RELIEF TABLET ER Y    
acetaminophen ARTHRITIS PAIN TABLET ER Y    
acetaminophen 8 HOUR ACETAMINOPHEN TABLET ER Y    
acetaminophen 8 HOUR PAIN RELIEF TABLET ER Y    
acetaminophen 8HR ARTHRITIS PAIN TABLET ER Y    
acetaminophen 8HR ARTHRITIS PAIN RELIEF TABLET ER Y    
acetaminophen 8HR MUSCLE ACHES-PAIN RELIEF TABLET ER Y    
acetaminophen 8HR ARTHRITIS PAIN TABLET ER Y    
acetaminophen PAIN RELIEVER TABLET ER Y    
acetaminophen TYLENOL 8 HOUR TABLET ER Y    
acetaminophen/caffeine TENSION HEADACHE TABLET Y    
acetaminophen/caffeine TENSION HEADACHE TABLET Y    
acetaminophen/caffeine TENSION HEADACHE PAIN RELIEVER TABLET Y    
acetaminophen/caffeine EXCEDRIN TENSION HEADACHE TABLET Y    
aspirin/acetaminophen/caffeine MIGRAINE RELIEF TABLET Y    
aspirin/acetaminophen/caffeine PAIN-OFF TABLET Y    
aspirin/acetaminophen/caffeine PAIN RELIEVER TABLET Y    
aspirin/acetaminophen/caffeine PAIN RELIEVER PLUS TABLET Y    
aspirin/acetaminophen/caffeine ASPIRIN-ACETAMINPHEN-CAFFEINE TABLET Y    
aspirin/acetaminophen/caffeine EXTRA PAIN RELIEF TABLET Y    
aspirin/acetaminophen/caffeine HEADACHE RELIEF TABLET Y    
aspirin/acetaminophen/caffeine MIGRAINE FORMULA TABLET Y    
aspirin/acetaminophen/caffeine MIGRAINE RELIEF TABLET Y    
aspirin/acetaminophen/caffeine PAIN RELIEVER PLUS TABLET Y    
aspirin/acetaminophen/caffeine VANQUISH TABLET Y    
aspirin/acetaminophen/caffeine EXCEDRIN EXTRA STRENGTH TABLET Y    
aspirin/acetaminophen/caffeine ADDED STRENGTH PAIN RELIEVER TABLET Y    
aspirin/acetaminophen/caffeine ADDED STRENGTH PAIN RELIEF TABLET Y    
aspirin/acetaminophen/caffeine ADDED STRENGTH HEADACHE TABLET Y    
aspirin/acetaminophen/caffeine EXTRAPRIN TABLET Y    
aspirin/acetaminophen/caffeine GOODY'S MIGRAINE RELIEF TABLET Y    
aspirin/acetaminophen/caffeine HEADACHE PAIN TABLET Y    
aspirin/acetaminophen/caffeine HEADACHE RELIEF TABLET Y    
aspirin/acetaminophen/caffeine EXCEDRIN MIGRAINE TABLET Y    
aspirin/acetaminophen/caffeine MIGRAINE FORMULA TABLET Y    
aspirin/caffeine BAYER BACK-BODY TABLET Y    
aspirin/caffeine BACK-BODY PAIN RELIEVER TABLET Y    
aspirin/caffeine BACK-BODY PAIN RELIEF TABLET Y    
aspirin/caffeine ANALGESIC TABLET Y    
aspirin/caffeine ANACIN TABLET Y    
aspirin/caffeine ADULT STRENGTH ANALGESIC TABLET Y    
aspirin/caffeine AA & C TABLET Y    
acetaminophen INFANT'S NON-ASPIRIN DROPS SUSP N    
acetaminophen CHILDREN'S ACETAMINOPHEN ORAL SUSP N    
acetaminophen ACETAMINOPHEN ORAL SUSP N    
acetaminophen ACETAMINOPHEN SOLUTION N    
acetaminophen ACETAMINOPHEN SYRINGE N    
acetaminophen/chlorpheniramine CORICIDIN HBP COLD AND FLU TABLET N    
acetaminophen/d-brompheniramin DOLOGESIC LIQUID N    
acetaminophen/d-brompheniramin DOLOGESIC TABLET N    
acetaminophen/d-brompheniramin DOLOGESIC-DF TABLET N    
acetaminophen/diphenhydramine ACETAMINOPHEN PM TABLET N    
acetaminophen/diphenhydramine ALLERGY SEVERE TABLET N    
acetaminophen/diphenhydramine EXT STR PAIN RELIEF/SLEEP TABLET N    
acetaminophen/diphenhydramine PAIN RELIEF PM TABLET N    
acetaminophen/diphenhydramine PAIN RELIEVER PM TABLET N    
acetaminophen/diphenhydramine PM PAIN RELIEF TABLET N    
acetaminophen/diphenhydramine PAIN RELIEVER TABLET SEQ N    
acetaminophen/phenyltoloxamine CONTRAGESIC TABLET N    
acetaminophen/pyrilam/pamabrom MENSTRUAL RELIEF TABLET N    
acetaminophen/pyrilam/pamabrom MENSTRUAL PAIN RELIEF TABLET N    
acetaminophen/pyrilamine/caff MENSTRUAL COMPLETE TABLET N    
ASA/acetaminophen/caffeine/cal SUPAC TABLET N    
aspirin/acetaminophn/diphenhyd PAIN RELIEF PM TABLET N    
aspirin/calcium carb/magnesium TRI-BUFFERED ASPIRIN TABLET N    
aspirin/calcium carb/magnesium BUFFERED ASPIRIN TABLET N    
aspirin/calcium/mag/aluminum ASPRIDROX TABLET N    
aspirin/sod bicarb/citric acid EFFERVESCENT PAIN RELIEF TABLET EFF N    
aspirin/sod bicarb/citric acid EFFERVESCENT ANTACID-PAIN RLF TABLET EFF N    
butalb/acetaminophen/caffeine BUTALBITAL-ACETAMINOPHEN-CAFFE CAPSULE N Pharmacy PA  
butalb/acetaminophen/caffeine FIORICET CAPSULE N Pharmacy PA  
butalb/acetaminophen/caffeine BUTALBITAL-ACETAMINOPHEN-CAFFE SOLUTION N Pharmacy PA  
butalb/acetaminophen/caffeine BUTALBITAL-ACETAMINOPHEN-CAFFE TABLET N Pharmacy PA  
butalb/acetaminophen/caffeine QUALA-CET TABLET N Pharmacy PA  
butalbital/acetaminophen BUTALBITAL-ACETAMINOPHEN CAPSULE N Pharmacy PA  
butalbital/acetaminophen BUTALBITAL-ACETAMINOPHEN TABLET N Pharmacy PA  
butalbital/acetaminophen REPAN-CF TABLET N Pharmacy PA  
butalbital/aspirin/caffeine BUTALBITAL-ASPIRIN-CAFFEINE CAPSULE N Pharmacy PA  
sal-amide/acetaminophen/p-tlox CETAZONE-T TABLET N    
choline salicyl/mag salicylate TRICOSAL TABLET    
ibuprofen/diphenhydramine cit IBUPROFEN PM TABLET    
suzetrigine JOURNAVX TABLET Pharmacy PA Jun 05, 2025
Back to Top ↑