Topical Nasal and Otic

← Back to Class List

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
acetic acid ACETIC ACID SOLUTION    
acetic acid/aluminum acetate DOMEBORO DROPS    
antipyrine/benzocaine A/B OTIC DROPS    
benzocaine OTICAINE DROPS    
carbamide peroxide EAR DROPS DROPS    
carbamide peroxide EAR WAX REMOVAL DROPS    
cocaine HCl COCAINE HCL SOLUTION    
cocaine HCl GOPRELTO SOLUTION    
cocaine HCl NUMBRINO SOLUTION    
fluocinolone acetonide oil FLUOCINOLONE ACETONIDE OIL DROPS    
fluocinolone acetonide oil FLAC OTIC OIL DROPS    
fluocinolone acetonide oil DERMOTIC DROPS    
hydrocort/pramoxine/chloroxyl CORTIC DROPS    
hydrocortisone/acetic acid HYDROCORTISONE-ACETIC ACID DROPS    
isopropyl alcohol in glycerin SWIM EAR DROPS    
isopropyl alcohol in glycerin EAR DROPS FOR SWIMMERS DROPS    
mometasone furoate SINUVA IMPLANT    
phenylephrine/antipy/benzocain EAR-GESIC DROPS    
salt irrigation solution no.1 OCEAN COMPLETE AER W/ADAP    
sod chlor,sod bicarb/neti pot SINUS WASH NETI POT PACK W/DEV    
sodium chloride SALINE NOSE SPRAY SPRAY    
sodium chloride AYR SPRAY    
sodium chloride/sodium bicarb SINUS WASH PACKET