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 | New Drug Evaluation |
|---|---|---|---|---|---|
| alcohol antiseptic pads | ALCOHOL PREP SWABS | MED. PAD | |||
| alcohol antiseptic pads | ALCOHOL SWAB | MED. PAD | |||
| alcohol antiseptic pads | ALCOHOL SWABS | MED. PAD | |||
| alcohol antiseptic pads | ALCOHOL WIPES | MED. PAD | |||
| alcohol antiseptic pads | ALCOHOL PREP PADS | MED. PAD | |||
| ammonium and potassium iodides | IODIDES | TINCTURE | |||
| benzalkonium chloride | TRIDERGEL | GEL (ML) | |||
| benzalkonium chloride | ONY-CLEAR | LIQUID | |||
| benzalkonium chloride | BENZ-ALL | LIQUID | |||
| benzalkonium chloride | BACTI-CLEANSE | SOLUTION | |||
| benzalkonium chloride | THERA BODY CLEANSER | SOLUTION | |||
| benzalkonium chloride | MEDISTAY 240 | SOLUTION | |||
| benzalkonium chloride | DERMACINRX DIASINC | SPRAY | |||
| benzalkonium chloride | OBSTETRICAL ANTISEPTIC | TOWELETTE | |||
| 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 | DYNAHEX | LIQUID | |||
| chlorhexidin/isopropyl alcohol | CHLORHEXIDINE GLUCONATE | LIQUID | |||
| chlorhexidine gluconate | ANTISEPTIC SKIN CLEANSER | LIQUID | |||
| chlorhexidine gluconate | BETASEPT | LIQUID | |||
| chlorhexidine gluconate | CHLORHEXIDINE GLUCONATE | LIQUID | |||
| chlorhexidine gluconate | DYNA-HEX | LIQUID | |||
| chlorhexidine gluconate | HAND SOAP | LIQUID | |||
| chloroxylenol | ANTIMICROBIAL LOTION SOAP | CLEANSER | |||
| clioquinol | CLIOQUINOL | CREAM (G) | |||
| ethyl alcohol | ETHYL ALCOHOL | SOLUTION | |||
| ethyl alcohol | INSTANT HAND SANITIZING | TOWELETTE | |||
| eucalyp/me-salicylate/men/thym | ANTISEPTIC | MOUTHWASH | |||
| fosfomycin tromethamine | FOSFOMYCIN TROMETHAMINE | PACKET | |||
| furazolidone | FUROXONE | TABLET | |||
| glycine urologic solution | GLYCINE | IRRIG SOLN | |||
| glycine urologic solution | AMINOACETIC ACID | IRRIG SOLN | |||
| glycolic acid | AQUA GLYCOLIC | LIQUID | |||
| hydrocortisone/iodoquinol | CORTI-SAV | CREAM (G) | |||
| 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 | MED. SWAB | |||
| povidone-iodine | POVIDONE-IODINE | MED. SWAB | |||
| povidone-iodine | POVIDONE-IODINE | OINT. (G) | |||
| povidone-iodine | FIRST AID ANTISEPTIC | OINT. (G) | |||
| povidone-iodine | POVIDONE-IODINE | PACKET | |||
| povidone-iodine | PVP PREP | SOLUTION | |||
| povidone-iodine | POVIDONE-IODINE | SOLUTION | |||
| povidone-iodine | BETADINE | 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 |