Anesthetics Local Topical

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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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
lidocaine LIDOCAINE ADH. PATCH N Pharmacy PA N  
lidocaine ULTRA LIDO GEL ADH. PATCH N Pharmacy PA N  
lidocaine PAIN RELIEF ADH. PATCH N Pharmacy PA N  
lidocaine ANLIDO ADH. PATCH N Pharmacy PA N  
lidocaine LIDOCAINE PAIN RELIEF ADH. PATCH N Pharmacy PA N  
lidocaine ULTRA LIDO CREAM (G) N   N  
lidocaine LIDOCAINE CREAM (G) N   N  
lidocaine HCl/menthol SYNOFLEX ADH. PATCH N   N  
lidocaine/methyl sal/menthol TRICEPTIN ADH. PATCH N   N  
benzocaine BENZOCAINE CREAM (G)   N  
benzocaine ORAL PAIN RELIEF GEL (GRAM)   N  
benzocaine ORASOL GEL PACKET   N  
benzocaine BENZOCAINE SPRAY   N  
benzocaine/aloe vera DERMACAINE W/ALOE CREAM (G)   N  
benzocaine/benzalk chl ORAL PAIN RELIEF GEL (GRAM)   N  
benzocaine/menth/cetylpyrd Cl ORASEP SOLUTION   N  
benzocaine/menth/cetylpyrd Cl ORASEP SPRAY   N  
benzocaine/menthol SORE THROAT LOZENGE LOZENGE   N  
benzocaine/resorcinol FEMININE ANTI-ITCH CREAM (G)   N  
benzocaine/resorcinol VAGICAINE CREAM (G)   N  
bupivacaine HCl BUPIVACAINE HCL VIAL   N  
bupivacaine HCl SENSORCAINE VIAL   N  
bupivacaine HCl MARCAINE VIAL   N  
bupivacaine HCl in dextrose/PF MARCAINE SPINAL AMPUL   N  
bupivacaine HCl in dextrose/PF BUPIVACAINE-DEXTROSE AMPUL   N  
bupivacaine HCl/epinephrine MARCAINE-EPINEPHRINE AMPUL   N  
bupivacaine HCl/epinephrine SENSORCAINE-EPINEPHRINE VIAL   N  
bupivacaine HCl/epinephrine MARCAINE-EPINEPHRINE VIAL   N  
bupivacaine HCl/epinephrine BUPIVACAINE HCL-EPINEPHRINE VIAL   N  
bupivacaine HCl/epinephrine/PF SENSORCAINE-MPF EPINEPHRINE VIAL   N  
bupivacaine HCl/epinephrine/PF MARCAINE-EPINEPHRINE VIAL   N  
bupivacaine HCl/epinephrine/PF BUPIVACAINE HCL-EPINEPHRINE VIAL   N  
bupivacaine HCl/PF BUPIVACAINE HCL AMPUL   N  
bupivacaine HCl/PF BUPIVACAINE HCL VIAL   N  
bupivacaine HCl/PF SENSORCAINE-MPF VIAL   N  
bupivacaine HCl/PF MARCAINE VIAL   N  
bupivacaine liposome/PF EXPAREL VIAL   N  
bupivacaine/meloxicam ZYNRELEF SOLER VIAL   N  
chloroprocaine HCl NESACAINE VIAL   N  
chloroprocaine HCl/PF NESACAINE-MPF VIAL   N  
chloroprocaine HCl/PF CHLOROPROCAINE HCL VIAL   N  
Cl-thymol/benzocaine/resor/iod DERMACAINE CREAM (G)   N  
dibucaine DIBUCAINE OINT. (G)   N  
dyclonine HCl/benzethonium Cl LIQUID BANDAGE SOLUTION   N  
lidocaine HCl LIDOCAINE HCL SYRINGE   N  
lidocaine HCl XYLOCAINE VIAL   N  
lidocaine HCl LIDOCAINE HCL VIAL   N  
lidocaine HCl/epinephrine XYLOCAINE WITH EPINEPHRINE VIAL   N  
lidocaine HCl/epinephrine LIDOCAINE HCL-EPINEPHRINE VIAL   N  
lidocaine HCl/epinephrine/PF LIDOCAINE HCL-EPINEPHRINE AMPUL   N  
lidocaine HCl/epinephrine/PF LIDOCAINE HCL W/EPINEPHRINE AMPUL   N  
lidocaine HCl/epinephrine/PF LIDOCAINE HCL-EPINEPHRINE VIAL   N  
lidocaine HCl/epinephrine/PF XYLOCAINE-MPF WITH EPINEPHRINE VIAL   N  
lidocaine HCl/epinephrine/PF XYLOCAINE WITH EPINEPHRINE VIAL   N  
lidocaine HCl/menthol ENDOXCIN ADH. PATCH   N  
lidocaine HCl/menthol LENZAPRO FLEX ADH. PATCH   N  
lidocaine HCl/menthol LENZAPATCH ADH. PATCH   N  
lidocaine HCl/menthol LENZAGEL GEL (GRAM)   N  
lidocaine HCl/menthol DERMACINRX LIDOCHILL GEL (ML)   N  
lidocaine HCl/PF XYLOCAINE-MPF AMPUL   N  
lidocaine HCl/PF LIDOCAINE HCL AMPUL   N  
lidocaine HCl/PF XYLOCAINE-MPF AMPUL LUER   N  
lidocaine HCl/PF XYLOCAINE-MPF VIAL   N  
lidocaine HCl/PF LIDOCAINE HCL VIAL   N  
lidocaine/aloe vera BURN RELIEF SPRAY   N  
lidocaine/benzalkonium/alcohol FIRST AID ANTISEPTIC SOLUTION   N  
lidocaine/menthol COLD AND HOT PAIN RELIEF ADH. PATCH   N  
lidocaine/menthol LIDOCAINE-MENTHOL ADH. PATCH   N  
lidocaine/transparent dressing LIDOCAINE KIT   N  
mepivacaine HCl POLOCAINE VIAL   N  
mepivacaine HCl/PF POLOCAINE-MPF VIAL   N  
phenazopyridine HCl PHENAZOPYRIDINE HCL TABLET   N  
phenazopyridine HCl URO-PAIN TABLET   N  
phenazopyridine HCl URINARY PAIN RELIEF TABLET   N  
phenazopyridine HCl PYRIDIUM TABLET   N  
phenazopyridine HCl PRODIUM TABLET   N  
phenol SORE THROAT SPRAY SPRAY   N  
phenol PHENASEPTIC SPRAY   N  
phenol/sodium phenolate SORE THROAT SPRAY SPRAY   N  
phenol/sodium phenolate MOUTHWASH/GARGLE SPRAY   N  
pramoxine HCl POISON IVY WASH CLEANSER   N  
pramoxine HCl PRAMOXINE HCL LOTION   N  
prilocaine HCl CITANEST AMPUL   N  
prilocaine HCl CITANEST VIAL   N  
ropivacaine HCl/PF NAROPIN AMPUL   N  
ropivacaine HCl/PF ROPIVACAINE HCL INFUS. BTL   N  
ropivacaine HCl/PF NAROPIN INFUS. BTL   N  
ropivacaine HCl/PF ROPIVACAINE HCL PLAST. BAG   N  
ropivacaine HCl/PF NAROPIN PLAST. BAG   N  
ropivacaine HCl/PF ROPIVACAINE HCL VIAL   N  
ropivacaine HCl/PF NAROPIN VIAL   N  
t-caine/menth/zinc ox/ichtham BURN OINTMENT OINT. (G)   N  
tetracaine PONTOCAINE OINT. (G)   N  
tetracaine HCl/PF TETRACAINE HCL VIAL   N  
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