General Actibacterial, Antibacterials
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| alcohol antiseptic pads | ALCOHOL SWABS | MED. PAD | N | |||
| alcohol antiseptic pads | ALCOHOL PREP SWABS | MED. PAD | N | |||
| alcohol antiseptic pads | ALCOHOL PREP PADS | MED. PAD | N | |||
| ammonium and potassium iodides | IODIDES | TINCTURE | N | |||
| benzalkonium chloride | THERA BODY CLEANSER | SOLUTION | N | |||
| benzalkonium chloride | DERMACINRX DIASINC | SPRAY | N | |||
| benzethonium chloride | FOAMING ANTIBACTERIAL SOAP | FOAM (ML) | N | |||
| boric acid | BORIC ACID | OINT. (G) | N | |||
| cetylpyridinium/domiphen brom | GREEN MOUTHWASH | MOUTHWASH | N | |||
| chlorhexidin/isopropyl alcohol | DYNAHEX | LIQUID | N | |||
| chlorhexidine gluconate | BETASEPT | LIQUID | N | |||
| chloroxylenol | ANTIMICROBIAL LOTION SOAP | CLEANSER | N | |||
| ethyl alcohol | ETHYL ALCOHOL | SOLUTION | N | |||
| ethyl alcohol | INSTANT HAND SANITIZING | TOWELETTE | N | |||
| eucalyp/me-salicylate/men/thym | ANTISEPTIC | MOUTHWASH | N | |||
| furazolidone | FUROXONE | TABLET | N | |||
| glycine urologic solution | AMINOACETIC ACID | IRRIG SOLN | N | |||
| hydrocortisone/iodoquinol | CORTI-SAV | CREAM (G) | N | |||
| iodine/potassium iodide | IODINE | TINCTURE | N | |||
| iodine/sodium iodide | IODINE | TINCTURE | N | |||
| isopropyl alcohol | ISOPROPYL ALCOHOL | MED. SWAB | N | |||
| nitrofurazone | FURACIN | CREAM (G) | N | |||
| physiological irrig soln no.1 | PHYSIOLYTE | IRRIG SOLN | N | |||
| povidone-iodine | POVIDONE-IODINE | MED. SWAB | N | |||
| povidone-iodine | BETADINE | MED. SWAB | N | |||
| povidone-iodine | FIRST AID ANTISEPTIC | OINT. (G) | N | |||
| povidone-iodine | POVIDONE-IODINE | SOLUTION | N | |||
| povidone-iodine | PVP PREP | SOLUTION | N | |||
| povidone-iodine | BETADINE | SOLUTION | N | |||
| silver nitrate | SILVER NITRATE | SOLUTION | N |