General Actibacterial, Antibacterials

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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
Current Drug Use Criteria New Drug Evaluation
alcohol antiseptic pads ALCOHOL WIPES MED. PAD    
alcohol antiseptic pads ALCOHOL SWABS MED. PAD    
alcohol antiseptic pads ALCOHOL SWAB MED. PAD    
alcohol antiseptic pads ALCOHOL PREP SWABS MED. PAD    
alcohol antiseptic pads ALCOHOL PREP PADS MED. PAD    
ammonium and potassium iodides IODIDES TINCTURE    
benzalkonium chloride ONY-CLEAR LIQUID    
benzalkonium chloride BENZ-ALL LIQUID    
benzalkonium chloride MEDISTAY 240 SOLUTION    
benzalkonium chloride BACTI-CLEANSE SOLUTION    
benzalkonium chloride THERA BODY CLEANSER SOLUTION    
benzalkonium chloride DERMACINRX DIASINC SPRAY    
benzethonium chloride ANTIBACTERIAL SOAP CLEANSER    
benzethonium chloride FOAMING ANTIBACTERIAL SOAP FOAM (ML)    
boric acid BORIC ACID OINT. (G)    
cetylpyridinium/domiphen brom GREEN MOUTHWASH MOUTHWASH    
chlorhexidin/isopropyl alcohol CHLORHEXIDINE GLUCONATE LIQUID    
chlorhexidin/isopropyl alcohol DYNAHEX LIQUID    
chlorhexidine gluconate DYNA-HEX LIQUID    
chlorhexidine gluconate ANTISEPTIC SKIN CLEANSER LIQUID    
chlorhexidine gluconate CHLORHEXIDINE GLUCONATE LIQUID    
chlorhexidine gluconate HAND SOAP LIQUID    
chlorhexidine gluconate SCRUB CARE EXIDINE LIQUID    
chlorhexidine gluconate BETASEPT LIQUID    
clioquinol CLIOQUINOL CREAM (G)    
ethyl alcohol ETHYL ALCOHOL SOLUTION    
eucalyp/me-salicylate/men/thym ANTISEPTIC MOUTHWASH    
fosfomycin tromethamine FOSFOMYCIN TROMETHAMINE PACKET    
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    
hydrogen peroxide HYDROGEN PEROXIDE SOLUTION    
iodine/potassium iodide LUGOL'S SOLUTION    
iodine/sodium iodide IODINE TINCTURE    
isopropyl alcohol ISOPROPYL ALCOHOL MED. SWAB    
isopropyl alcohol/benzocaine ALCOHOL PADS WITH BENZOCAINE MED. PAD    
nitrofurazone FURACIN CREAM (G)    
nitrofurazone FURACIN OINT. (G)    
physiological irrig soln no.1 PHYSIOSOL IRRIG SOLN    
physiological irrig soln no.1 PHYSIOLYTE IRRIG SOLN    
povidone-iodine BETADINE CREAM (G)    
povidone-iodine BETADINE MED. SWAB    
povidone-iodine POVIDONE-IODINE MED. SWAB    
povidone-iodine FIRST AID ANTISEPTIC OINT. (G)    
povidone-iodine POVIDONE-IODINE OINT. (G)    
povidone-iodine POVIDONE-IODINE PACKET    
povidone-iodine BETADINE SOLUTION    
povidone-iodine PVP PREP SOLUTION    
povidone-iodine POVIDONE-IODINE SOLUTION    
povidone-iodine BETADINE SPRAY    
silver nitrate SILVER NITRATE SOLUTION    
sodium chloride irrig solution SODIUM CHLORIDE IRRIG SOLN    
sodium hypochlorite HYSEPT SOLUTION    
urologic solution-G UROLOGIC SOLUTION G IRRIG SOLN    
water for irrigation,sterile WATER IRRIG SOLN