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.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
lidocaine LIDOCAINE PAIN RELIEF ADH. PATCH N PA Document  
lidocaine LIDOCAINE ADH. PATCH N PA Document  
lidocaine LIDOCAINE CREAM (G) N    
lidocaine HCl/menthol SYNOFLEX ADH. PATCH N    
benzocaine BENZOCAINE CREAM (G)    
benzocaine ORAL PAIN RELIEF GEL (GRAM)    
benzocaine/aloe vera DERMACAINE W/ALOE CREAM (G)    
benzocaine/menth/cetylpyrd Cl ORASEP SPRAY    
benzocaine/menthol SORE THROAT LOZENGE    
benzocaine/menthol SORE THROAT LOZENGE LOZENGE    
benzocaine/menthol MUCINEX INSTASOOTHE PAIN RLF SPRAY    
benzocaine/resorcin/aloe/E,A,D ANTI-ITCH VAGINAL MAX STRENGTH CREAM (G)    
benzocaine/resorcinol VAGICAINE CREAM (G)    
benzocaine/resorcinol VAGINAL ITCH CREAM CREAM (G)    
bupivacaine HCl BUPIVACAINE HCL VIAL    
bupivacaine HCl SENSORCAINE VIAL    
bupivacaine HCl MARCAINE VIAL    
bupivacaine HCl in dextrose/PF BUPIVACAINE-DEXTROSE AMPUL    
bupivacaine HCl in dextrose/PF MARCAINE SPINAL AMPUL    
bupivacaine HCl/epinephrine MARCAINE-EPINEPHRINE AMPUL    
bupivacaine HCl/epinephrine BUPIVACAINE HCL-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine MARCAINE-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine SENSORCAINE-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine/PF BUPIVACAINE HCL-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine/PF MARCAINE-EPINEPHRINE VIAL    
bupivacaine HCl/epinephrine/PF SENSORCAINE-MPF EPINEPHRINE VIAL    
bupivacaine HCl/PF BUPIVACAINE HCL AMPUL    
bupivacaine HCl/PF BUPIVACAINE HCL VIAL    
bupivacaine HCl/PF MARCAINE VIAL    
bupivacaine HCl/PF SENSORCAINE-MPF VIAL    
bupivacaine/meloxicam ZYNRELEF SOLER VIAL    
chloroprocaine HCl NESACAINE VIAL    
chloroprocaine HCl/PF CLOROTEKAL AMPUL    
chloroprocaine HCl/PF NESACAINE-MPF VIAL    
chloroprocaine HCl/PF CHLOROPROCAINE HCL VIAL    
Cl-thymol/benzocaine/resor/iod DERMACAINE CREAM (G)    
dibucaine DIBUCAINE OINT. (G)    
lidocaine HCl LIDOCAINE HCL SYRINGE    
lidocaine HCl XYLOCAINE VIAL    
lidocaine HCl LIDOCAINE HCL VIAL    
lidocaine HCl/benzalkonium chl FIRST AID ANTISEPTIC SPRAY    
lidocaine HCl/dextrose 7.5%/PF LIDOCAINE HCL IN 7.5% DEXTROSE AMPUL    
lidocaine HCl/epinephrine LIDOCAINE HCL-EPINEPHRINE VIAL    
lidocaine HCl/epinephrine XYLOCAINE WITH EPINEPHRINE VIAL    
lidocaine HCl/epinephrine/PF LIDOCAINE HCL W/EPINEPHRINE AMPUL    
lidocaine HCl/epinephrine/PF LIDOCAINE HCL-EPINEPHRINE AMPUL    
lidocaine HCl/epinephrine/PF XYLOCAINE-MPF WITH EPINEPHRINE VIAL    
lidocaine HCl/epinephrine/PF XYLOCAINE WITH EPINEPHRINE VIAL    
lidocaine HCl/epinephrine/PF LIDOCAINE HCL-EPINEPHRINE VIAL    
lidocaine HCl/menthol LENZAPRO FLEX ADH. PATCH    
lidocaine HCl/PF LIDOCAINE HCL AMPUL    
lidocaine HCl/PF XYLOCAINE-MPF AMPUL    
lidocaine HCl/PF XYLOCAINE-MPF AMPUL LUER    
lidocaine HCl/PF LIDOCAINE HCL VIAL    
lidocaine HCl/PF XYLOCAINE-MPF VIAL    
lidocaine/aloe vera BURN RELIEF SPRAY    
lidocaine/benzalkonium/alcohol FIRST AID ANTISEPTIC SOLUTION    
lidocaine/menthol COLD AND HOT PAIN RELIEF ADH. PATCH    
lidocaine/menthol LENZAPRO ADH. PATCH    
lidocaine/menthol LIDOCAINE-MENTHOL ADH. PATCH    
lidocaine/transparent dressing LIDOCAINE KIT    
mepivacaine HCl POLOCAINE VIAL    
mepivacaine HCl CARBOCAINE VIAL    
mepivacaine HCl/PF CARBOCAINE VIAL    
mepivacaine HCl/PF POLOCAINE-MPF VIAL    
phenazopyridine HCl PHENAZOPYRIDINE HCL TABLET    
phenazopyridine HCl PYRIDIUM TABLET    
phenazopyridine HCl URINARY PAIN RELIEF TABLET    
phenazopyridine HCl PRODIUM TABLET    
phenol PHENASEPTIC SPRAY    
phenol SORE THROAT SPRAY SPRAY    
phenol/sodium phenolate SORE THROAT SPRAY SPRAY    
phenol/sodium phenolate MOUTHWASH/GARGLE SPRAY    
pramoxine HCl POISON IVY WASH CLEANSER    
pramoxine HCl PRAMOXINE HCL LOTION    
prilocaine HCl CITANEST AMPUL    
prilocaine HCl CITANEST VIAL    
ropivacaine HCl/PF NAROPIN AMPUL    
ropivacaine HCl/PF NAROPIN INFUS. BTL    
ropivacaine HCl/PF ROPIVACAINE HCL INFUS. BTL    
ropivacaine HCl/PF ROPIVACAINE HCL PLAST. BAG    
ropivacaine HCl/PF NAROPIN PLAST. BAG    
ropivacaine HCl/PF ROPIVACAINE HCL VIAL    
ropivacaine HCl/PF NAROPIN VIAL    
t-caine/menth/zinc ox/ichtham BURN OINTMENT OINT. (G)    
tetracaine PONTOCAINE OINT. (G)    
tetracaine HCl/PF TETRACAINE HCL AMPUL    
tetracaine HCl/PF TETRACAINE HCL VIAL