Anesthetics Local Topical
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 | PAIN RELIEF | ADH. PATCH | N | PA Document | |
lidocaine | ULTRA LIDO GEL | ADH. PATCH | N | PA Document | |
lidocaine | LIDOCAINE | ADH. PATCH | N | PA Document | |
lidocaine | LIDOCAINE PAIN RELIEF | ADH. PATCH | N | PA Document | |
lidocaine | ULTRA LIDO | CREAM (G) | N | ||
lidocaine | LIDOCAINE | CREAM (G) | N | ||
lidocaine HCl/menthol | SYNOFLEX | ADH. PATCH | N | ||
lidocaine/methyl sal/menthol | TRICEPTIN | ADH. PATCH | N | ||
tetracaine | TETRI-AG | OINT. (G) | N | ||
benzocaine | BENZOCAINE | CREAM (G) | |||
benzocaine | ORAL PAIN RELIEF | GEL (GRAM) | |||
benzocaine | BENZOCAINE | SPRAY | |||
benzocaine/aloe vera | DERMACAINE W/ALOE | CREAM (G) | |||
benzocaine/menth/cetylpyrd Cl | ORASEP | SOLUTION | |||
benzocaine/menth/cetylpyrd Cl | ORASEP | SPRAY | |||
benzocaine/menthol | SORE THROAT LOZENGE | LOZENGE | |||
benzocaine/resorcinol | VAGICAINE | CREAM (G) | |||
bupivacaine HCl | MARCAINE | VIAL | |||
bupivacaine HCl | SENSORCAINE | VIAL | |||
bupivacaine HCl | BUPIVACAINE HCL | VIAL | |||
bupivacaine HCl in dextrose/PF | MARCAINE SPINAL | AMPUL | |||
bupivacaine HCl in dextrose/PF | BUPIVACAINE-DEXTROSE | AMPUL | |||
bupivacaine HCl/epinephrine | MARCAINE-EPINEPHRINE | AMPUL | |||
bupivacaine HCl/epinephrine | SENSORCAINE-EPINEPHRINE | VIAL | |||
bupivacaine HCl/epinephrine | MARCAINE-EPINEPHRINE | VIAL | |||
bupivacaine HCl/epinephrine | BUPIVACAINE HCL-EPINEPHRINE | VIAL | |||
bupivacaine HCl/epinephrine/PF | SENSORCAINE-MPF EPINEPHRINE | VIAL | |||
bupivacaine HCl/epinephrine/PF | MARCAINE-EPINEPHRINE | VIAL | |||
bupivacaine HCl/epinephrine/PF | BUPIVACAINE HCL-EPINEPHRINE | VIAL | |||
bupivacaine HCl/PF | BUPIVACAINE HCL | AMPUL | |||
bupivacaine HCl/PF | MARCAINE | VIAL | |||
bupivacaine HCl/PF | SENSORCAINE-MPF | VIAL | |||
bupivacaine HCl/PF | BUPIVACAINE HCL | VIAL | |||
bupivacaine liposome/PF | EXPAREL | 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) | |||
dyclonine HCl/benzethonium Cl | LIQUID BANDAGE | SOLUTION | |||
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 | XYLOCAINE WITH EPINEPHRINE | VIAL | |||
lidocaine HCl/epinephrine | LIDOCAINE HCL-EPINEPHRINE | VIAL | |||
lidocaine HCl/epinephrine/PF | LIDOCAINE HCL-EPINEPHRINE | AMPUL | |||
lidocaine HCl/epinephrine/PF | LIDOCAINE HCL W/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 | XYLOCAINE-MPF | AMPUL | |||
lidocaine HCl/PF | LIDOCAINE HCL | AMPUL | |||
lidocaine HCl/PF | XYLOCAINE-MPF | AMPUL LUER | |||
lidocaine HCl/PF | XYLOCAINE-MPF | VIAL | |||
lidocaine HCl/PF | LIDOCAINE HCL | 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 | LIDOCAINE-MENTHOL | ADH. PATCH | |||
lidocaine/transparent dressing | LIDOCAINE | KIT | |||
mepivacaine HCl | POLOCAINE | VIAL | |||
mepivacaine HCl/PF | POLOCAINE-MPF | VIAL | |||
phenazopyridine HCl | PHENAZOPYRIDINE HCL | TABLET | |||
phenazopyridine HCl | PRODIUM | TABLET | |||
phenazopyridine HCl | PYRIDIUM | TABLET | |||
phenazopyridine HCl | URO-PAIN | TABLET | |||
phenazopyridine HCl | URINARY PAIN RELIEF | TABLET | |||
phenol | SORE THROAT SPRAY | SPRAY | |||
phenol | PHENASEPTIC | 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 | ROPIVACAINE HCL | INFUS. BTL | |||
ropivacaine HCl/PF | NAROPIN | 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 | VIAL |