Misc Analgesics

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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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
acetaminophen/d-brompheniramin DOLOGESIC TABLET N   N  
acetaminophen/d-brompheniramin DOLOGESIC-DF TABLET N   N  
acetaminophen/diphenhydramine PM PAIN RELIEF TABLET N   N  
acetaminophen/diphenhydramine PAIN RELIEVER PM TABLET N   N  
acetaminophen/diphenhydramine ACETAMINOPHEN PM TABLET N   N  
acetaminophen/diphenhydramine EXT STR PAIN RELIEF/SLEEP TABLET N   N  
acetaminophen/diphenhydramine PAIN RELIEF PM TABLET N   N  
aspirin/acetaminophn/diphenhyd PAIN RELIEF PM TABLET N   N  
butalb/acetaminophen/caffeine FIORICET CAPSULE N Pharmacy PA N  
butalb/acetaminophen/caffeine BUTALBITAL-ACETAMINOPHEN-CAFFE CAPSULE N Pharmacy PA N  
butalb/acetaminophen/caffeine BUTALBITAL-ACETAMINOPHEN-CAFFE SOLUTION N Pharmacy PA N  
butalb/acetaminophen/caffeine QUALA-CET TABLET N Pharmacy PA N  
butalb/acetaminophen/caffeine BUTALBITAL-ACETAMINOPHEN-CAFFE TABLET N Pharmacy PA N  
butalbital/acetaminophen BUTALBITAL-ACETAMINOPHEN CAPSULE N Pharmacy PA N  
butalbital/acetaminophen REPAN-CF TABLET N Pharmacy PA N  
butalbital/acetaminophen BUTALBITAL-ACETAMINOPHEN TABLET N Pharmacy PA N  
butalbital/aspirin/caffeine BUTALBITAL-ASPIRIN-CAFFEINE CAPSULE N Pharmacy PA N  
acetaminophen MAPAP CAPSULE   N  
acetaminophen INFANT DROPS DROPS   N  
acetaminophen INFANT'S NON-ASPIRIN DROPS   N  
acetaminophen INFANT'S NON-ASPIRIN DROPS SUSP   N  
acetaminophen ACETAMINOPHEN ELIXIR   N  
acetaminophen REDUTEMP LIQUID   N  
acetaminophen ACETAMINOPHEN LIQUID   N  
acetaminophen M-PAP LIQUID   N  
acetaminophen MAPAP LIQUID   N  
acetaminophen ED-APAP LIQUID   N  
acetaminophen CHILDREN'S PAIN AND FEVER LIQUID   N  
acetaminophen CHILDREN'S ACETAMINOPHEN LIQUID   N  
acetaminophen ACETAMINOPHEN ORAL SUSP   N  
acetaminophen MAPAP CHILDREN'S ORAL SUSP   N  
acetaminophen INFANTS' ACETAMINOPHEN ORAL SUSP   N  
acetaminophen INFANTS' PAIN-FEVER ORAL SUSP   N  
acetaminophen CHILDREN'S PAIN-FEVER ORAL SUSP   N  
acetaminophen CHILDREN'S PAIN RELIEF ORAL SUSP   N  
acetaminophen CHILDREN'S ACETAMINOPHEN ORAL SUSP   N  
acetaminophen ACETAMINOPHEN PIGGYBACK   N  
acetaminophen ACETAMINOPHEN SOLUTION   N  
acetaminophen ACETAMINOPHEN SUPP.RECT   N  
acetaminophen CHILDREN'S PAIN RELIEVER SUPP.RECT   N  
acetaminophen FEVERALL SUPP.RECT   N  
acetaminophen PAIN RELIEVER SUPP.RECT   N  
acetaminophen ACETAMINOPHEN SYRINGE   N  
acetaminophen CHILDREN'S PAIN-FEVER RELIEF TAB CHEW   N  
acetaminophen CHILDREN'S PAIN RELIEF TAB CHEW   N  
acetaminophen CHILDREN'S MAPAP TAB CHEW   N  
acetaminophen CHILDREN'S ACETAMINOPHEN TAB CHEW   N  
acetaminophen PAIN RELIEVER JUNIOR STRENGTH TAB CHEW   N  
acetaminophen ACETAMINOPHEN TABLET   N  
acetaminophen PAIN RELIEF TABLET   N  
acetaminophen PAIN RELIEF EXTRA STRENGTH TABLET   N  
acetaminophen PAIN RELIEVER TABLET   N  
acetaminophen ARTHRITIS PAIN RELIEF TABLET ER   N  
acetaminophen ARTHRITIS PAIN TABLET ER   N  
acetaminophen 8 HOUR PAIN RELIEF TABLET ER   N  
acetaminophen ACETAMINOPHEN ER TABLET ER   N  
acetaminophen 8HR ARTHRITIS PAIN TABLET ER   N  
acetaminophen 8HR ARTHRITIS PAIN RELIEF TABLET ER   N  
acetaminophen ARTHRITIS PAIN RELIEVER TABLET ER   N  
acetaminophen 8 HOUR ACETAMINOPHEN TABLET ER   N  
acetaminophen PAIN RELIEVER TABLET ER   N  
acetaminophen ACETAMINOPHEN VIAL   N  
acetaminophen/caffeine TENSION HEADACHE TABLET   N  
acetaminophen/chlorpheniramine CORICIDIN HBP COLD AND FLU TABLET   N  
acetaminophen/diphenhydramine ALLERGY SEVERE TABLET   N  
acetaminophen/diphenhydramine PAIN RELIEVER TABLET SEQ   N  
acetaminophen/phenyltoloxamine CONTRAGESIC TABLET   N  
acetaminophen/pyrilam/pamabrom MENSTRUAL RELIEF TABLET   N  
acetaminophen/pyrilam/pamabrom MENSTRUAL PAIN RELIEF TABLET   N  
acetaminophen/pyrilamine/caff MENSTRUAL COMPLETE TABLET   N  
ASA/acetaminophen/caffeine/cal SUPAC TABLET   N  
aspirin ASPIRIN SUPP.RECT   N  
aspirin/acetaminophen/caffeine PAIN RELIEVER PLUS TABLET   N  
aspirin/acetaminophen/caffeine MIGRAINE RELIEF TABLET   N  
aspirin/acetaminophen/caffeine MIGRAINE FORMULA TABLET   N  
aspirin/acetaminophen/caffeine HEADACHE RELIEF TABLET   N  
aspirin/acetaminophen/caffeine ASPIRIN-ACETAMINPHEN-CAFFEINE TABLET   N  
aspirin/acetaminophen/caffeine EXTRA PAIN RELIEF TABLET   N  
aspirin/caffeine AA & C TABLET   N  
aspirin/calcium carb/magnesium TRI-BUFFERED ASPIRIN TABLET   N  
aspirin/calcium carb/magnesium BUFFERED ASPIRIN TABLET   N  
aspirin/calcium/mag/aluminum ASPRIDROX TABLET   N  
aspirin/sod bicarb/citric acid EFFERVESCENT PAIN RELIEF TABLET EFF   N  
aspirin/sod bicarb/citric acid EFFERVESCENT ANTACID-PAIN RLF TABLET EFF   N  
choline salicyl/mag salicylate TRICOSAL TABLET   N  
clonidine HCl/PF DURACLON VIAL   N  
clonidine HCl/PF CLONIDINE HCL VIAL   N  
dihydroergotamine mesylate DIHYDROERGOTAMINE MESYLATE AMPUL   N  
dihydroergotamine mesylate DIHYDROERGOTAMINE MESYLATE SPRAY/PUMP   N  
dimethyl sulfoxide RIMSO-50 SOLUTION   N  
ergotamine tartrate ERGOMAR TAB SUBL   N  
ibuprofen/diphenhydramine cit IBUPROFEN PM TABLET   N  
ketorolac tromethamine KETOROLAC TROMETHAMINE CARTRIDGE   N  
ketorolac tromethamine TORADOL CARTRIDGE   N  
ketorolac tromethamine KETOROLAC TROMETHAMINE SYRINGE   N  
ketorolac tromethamine KETOROLAC TROMETHAMINE VIAL   N  
pentosan polysulfate sodium ELMIRON CAPSULE   N  
sal-amide/acetaminophen/p-tlox CETAZONE-T TABLET   N  
suzetrigine JOURNAVX TABLET Pharmacy PA N Jun 05, 2025
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