Hemorroidal Preps
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 |
|---|---|---|---|---|---|---|
| lidocaine | LIDOCAINE | CREAM (G) | N | N | ||
| lidocaine | RECTASMOOTHE | CREAM (G) | N | N | ||
| calamine/zinc oxide | HEMORRHOIDAL | SUPP.RECT | N | |||
| hydrocortisone/lidocaine/aloe | LIDOCAINE-HYDROCORTISONE | GEL W/APPL | N | |||
| hydrocortisone/lidocaine/aloe | ANA-LEX | KIT | N | |||
| hydrocortisone/pramoxine | HYDROCORTISONE-PRAMOXINE | CREAM/APPL | N | |||
| hydrocortisone/pramoxine | PROCTOFOAM-HC | FOAM | N | |||
| pe/shark liver oil/glyc/wh.pet | HEMORRHOIDAL CREAM | CREAM (G) | N | |||
| phenyleph/pramoxin/glycr/w.pet | HEMORRHOIDAL PAIN RELIEF | CREAM (G) | N | |||
| phenyleph/shark oil/cocoa butr | PREP-HEM | SUPP.RECT | N | |||
| phenylephrine HCl/hard fat | HEMORRHOIDAL SUPPOSITORY | SUPP.RECT | N | |||
| pramoxine HCl | PRAMOXINE HCL | FOAM | N | |||
| soybean oil/starch | HEMORRHOIDAL | SUPP.RECT | N | |||
| witch hazel | HEMORRHOIDAL PADS | MED. PAD | N | |||
| witch hazel | MEDI-PADS | MED. PAD | N |