Topical Nasal and Otic

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
52817081615 ACETIC ACID acetic acid SOLUTION 2 % Y N  
62135080151 ACETIC ACID acetic acid SOLUTION 2 % Y N  
64980042415 ACETIC ACID acetic acid SOLUTION 2 % Y N  
00026431202 DOMEBORO acetic acid/aluminum acetate DROPS 2 % Y N  
00254901043 A/B OTIC antipyrine/benzocaine DROPS 5.4 %-1.4 % Y N  
00254933943 OTICAINE benzocaine DROPS 20 % Y N  
00904662735 EAR DROPS carbamide peroxide DROPS 6.5 % Y N  
00904747835 EAR WAX REMOVAL carbamide peroxide DROPS 6.5 % Y N  
11527014351 EAR WAX REMOVAL carbamide peroxide DROPS 6.5 % Y N  
11527081074 EAR WAX REMOVAL carbamide peroxide DROPS 6.5 % Y N  
46122055605 EAR WAX REMOVAL carbamide peroxide DROPS 6.5 % Y N  
46122055705 EAR WAX REMOVAL carbamide peroxide DROPS 6.5 % Y N  
70000049001 EAR WAX REMOVAL carbamide peroxide DROPS 6.5 % Y N  
70000049002 EAR WAX REMOVAL carbamide peroxide DROPS 6.5 % Y N  
70677115301 EAR WAX REMOVAL carbamide peroxide DROPS 6.5 % Y N  
70677115401 EAR WAX REMOVAL carbamide peroxide DROPS 6.5 % Y N  
64950036204 COCAINE HCL cocaine HCl SOLUTION 4 % Y N  
70839036204 COCAINE HCL cocaine HCl SOLUTION 4 % Y N  
81665030102 COCAINE HCL cocaine HCl SOLUTION 4 % Y N  
64950035904 GOPRELTO cocaine HCl SOLUTION 4 % Y N  
81665030002 NUMBRINO cocaine HCl SOLUTION 4 % Y N  
68791010320 DERMOTIC fluocinolone acetonide oil DROPS 0.01 % Y N  
45802000910 FLUOCINOLONE ACETONIDE OIL fluocinolone acetonide oil DROPS 0.01 % Y N  
64980032920 FLUOCINOLONE ACETONIDE OIL fluocinolone acetonide oil DROPS 0.01 % Y N  
70752015920 FLUOCINOLONE ACETONIDE OIL fluocinolone acetonide oil DROPS 0.01 % Y N  
00642001101 CORTIC hydrocort/pramoxine/chloroxyl DROPS 10 mg-10 mg-1 mg/mL Y N  
00713084909 HYDROCORTISONE-ACETIC ACID hydrocortisone/acetic acid DROPS 1 %-2 % Y N  
51672300701 HYDROCORTISONE-ACETIC ACID hydrocortisone/acetic acid DROPS 1 %-2 % Y N  
71656006410 HYDROCORTISONE-ACETIC ACID hydrocortisone/acetic acid DROPS 1 %-2 % Y N  
70000047801 EAR DROPS FOR SWIMMERS isopropyl alcohol in glycerin DROPS 95 %-5 % Y N  
00168012691 SWIM EAR isopropyl alcohol in glycerin DROPS 95 %-5 % Y N  
10599000301 SINUVA mometasone furoate IMPLANT 1,350 mcg Y N  
00254934043 EAR-GESIC phenylephrine/antipy/benzocain DROPS 0.25 %-5 %-5 % Y N  
70000027001 SINUS WASH NETI POT sod chlor,sod bicarb/neti pot PACK W/DEV Y N  
71800002104 NASAL MOISTURIZING sodium chloride SPRAY 0.65 % Y N  
71800002105 NASAL MOISTURIZING sodium chloride SPRAY 0.65 % Y N  
83035106305 NASAL MOISTURIZING sodium chloride SPRAY 0.65 % Y N  
83592004405 NASAL MOISTURIZING sodium chloride SPRAY 0.65 % Y N  
45802031758 SALINE NOSE SPRAY sodium chloride SPRAY 0.65 % Y N  
70000027002 SINUS WASH sodium chloride/sodium bicarb PACKET 2,300 mg-700 mg Y N  
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