Misc Analgesics
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 |
|---|---|---|---|---|---|---|
| acetaminophen | ACETAMINOPHEN | PIGGYBACK | N | |||
| acetaminophen | PAIN RELIEVER | SUPP.RECT | N | |||
| acetaminophen | FEVERALL | SUPP.RECT | N | |||
| acetaminophen | CHILDREN'S PAIN RELIEVER | SUPP.RECT | N | |||
| acetaminophen | ACETAMINOPHEN | SUPP.RECT | N | |||
| acetaminophen | ACETAMINOPHEN | VIAL | N | |||
| aspirin | ASPIRIN | SUPP.RECT | N | |||
| clonidine HCl/PF | CLONIDINE HCL | VIAL | N | |||
| clonidine HCl/PF | DURACLON | 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 | |||
| 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 |