Topical Nasal and Otic
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 |
|---|---|---|---|---|---|
| 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 | 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 | NASAL MOISTURIZING | SPRAY | |||
| sodium chloride/sodium bicarb | SINUS WASH | PACKET |