General Actibacterial, Antibacterials

← 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 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
Current Drug Use Criteria New Drug Evaluation
clioquinol/hydrocortis/emol 88 DERMASORB AF CREAM (G) N    
alcohol antiseptic pads ALCOHOL PREP PADS MED. PAD    
alcohol antiseptic pads ALCOHOL PREP SWABS MED. PAD    
alcohol antiseptic pads ALCOHOL SWABS MED. PAD    
alcohol antiseptic pads ALCOHOL WIPES MED. PAD    
alcohol antiseptic pads ALCOHOL SWAB MED. PAD    
ammonium and potassium iodides IODIDES TINCTURE    
benzalkonium chloride GERM BLOC FOAM (ML)    
benzalkonium chloride BENZ-ALL LIQUID    
benzalkonium chloride CURE CHROME LIQUID    
benzalkonium chloride ONY-CLEAR LIQUID    
benzalkonium chloride REMEDY LIQUID    
benzalkonium chloride GERM BLOC LOTION    
benzalkonium chloride COLD SORE TREATMENT SOL W/APPL    
benzalkonium chloride BACTI-CLEANSE SOLUTION    
boric acid BORIC ACID OINT. (G)    
carbamide peroxide ORAL ANTISEPTIC SOLUTION    
cetylpyridinium/domiphen brom GREEN MOUTHWASH MOUTHWASH    
chlorhexidin/isopropyl alcohol CHLORHEXIDINE GLUCONATE LIQUID    
chlorhexidin/isopropyl alcohol DYNAHEX LIQUID    
chlorhexidine gluconate ANTISEPTIC SKIN CLEANSER LIQUID    
chlorhexidine gluconate BETASEPT LIQUID    
chlorhexidine gluconate DYNAHEX LIQUID    
chlorhexidine gluconate DYNA-HEX LIQUID    
clioquinol CLIOQUINOL CREAM (G)    
clioquinol/hydrocortisone IODOCHLORHYDROXYQUIN W/HC CREAM (G)    
clioquinol/hydrocortisone ALA-QUIN CREAM (G)    
ethyl alcohol EPI-CLENZ FOAM (ML)    
ethyl alcohol HAND SANITIZER GEL (ML)    
ethyl alcohol EPI-CLENZ GEL (ML)    
ethyl alcohol ETHYL ALCOHOL SOLUTION    
eucalyp/me-salicylate/men/thym CITRUS ANTISEPTIC MOUTHWASH    
eucalyp/me-salicylate/men/thym ORIGINAL ANTISEPTIC MOUTHWASH    
eucalyp/me-salicylate/men/thym SPRING MINT ANTISEPTIC MOUTHWASH    
eucalyp/me-salicylate/men/thym BLUE MINT ANTISEPTIC MOUTHWASH    
eucalyp/me-salicylate/men/thym ANTISEPTIC MOUTHWASH    
fosfomycin tromethamine MONUROL PACKET    
furazolidone FUROXONE TABLET    
glycine urologic solution GLYCINE IRRIG SOLN    
glycine urologic solution AMINOACETIC ACID IRRIG SOLN    
glycolic acid AQUA GLYCOLIC LIQUID    
hydrocortisone/iodoquin/aloe 2 IODOQUINOL-HYDROCORTISONE-ALOE GEL (GRAM)    
hydrocortisone/iodoquinol HYDROCORTISONE-IODOQUINOL CREAM (G)    
hydrogen peroxide HYDROGEN PEROXIDE SOLUTION    
iodine/potassium iodide LUGOL'S SOLUTION    
iodine/sodium iodide IODINE TINCTURE    
isopropyl alcohol/benzocaine ALCOHOL PADS WITH BENZOCAINE MED. PAD    
nitrofurazone FURACIN CREAM (G)    
nitrofurazone NITROFURAZONE OINT. (G)    
nitrofurazone FURACIN OINT. (G)    
oxychlorosene sodium CLORPACTIN WCS-90 SOLN RECON    
physiological irrig soln no.1 PHYSIOLYTE IRRIG SOLN    
physiological irrig soln no.1 PHYSIOSOL IRRIG SOLN    
povidone-iodine BETADINE CLEANSER    
povidone-iodine BETADINE MED. SWAB    
povidone-iodine POVIDONE-IODINE OINT. (G)    
povidone-iodine POVIDONE-IODINE PACKET    
povidone-iodine POVIDONE-IODINE SOLUTION    
povidone-iodine BETADINE SOLUTION    
povidone-iodine BETADINE SPRAY    
silver nitrate SILVER NITRATE SOLUTION    
silver/sodium alginate ARGLAES POWDER    
sodium chloride irrig solution SODIUM CHLORIDE IRRIG SOLN    
sodium hypochlorite H-CHLOR GEL (GRAM)    
sodium hypochlorite HYSEPT SOLUTION    
sodium hypochlorite H-CHLOR 6 SOLUTION    
sodium hypochlorite H-CHLOR 12 SOLUTION    
triclosan CETAPHIL BAR    
urologic solution-G UROLOGIC SOLUTION G IRRIG SOLN    
water for irrigation,sterile WATER IRRIG SOLN