General Actibacterial, Antibacterials

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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
00536110301 ALCOHOL PREP PADS alcohol antiseptic pads MED. PAD Y N  
49348089610 ALCOHOL PREP PADS alcohol antiseptic pads MED. PAD Y N  
62011004501 ALCOHOL PREP PADS alcohol antiseptic pads MED. PAD Y N  
68599580402 ALCOHOL PREP PADS alcohol antiseptic pads MED. PAD Y N  
68599580404 ALCOHOL PREP PADS alcohol antiseptic pads MED. PAD Y N  
68599580405 ALCOHOL PREP PADS alcohol antiseptic pads MED. PAD Y N  
82098081410 ALCOHOL PREP PADS alcohol antiseptic pads MED. PAD Y N  
83324030501 ALCOHOL PREP PADS alcohol antiseptic pads MED. PAD Y N  
24385006576 ALCOHOL PREP SWABS alcohol antiseptic pads MED. PAD Y N  
46122004378 ALCOHOL SWAB alcohol antiseptic pads MED. PAD Y N  
00113200078 ALCOHOL SWABS alcohol antiseptic pads MED. PAD Y N  
70000011201 ALCOHOL SWABS alcohol antiseptic pads MED. PAD Y N  
70000002601 ALCOHOL WIPES alcohol antiseptic pads MED. PAD Y N  
24385020746 IODIDES ammonium and potassium iodides TINCTURE Y N  
49348071130 IODIDES ammonium and potassium iodides TINCTURE Y N  
62011011601 IODIDES ammonium and potassium iodides TINCTURE Y N  
70000039901 IODIDES ammonium and potassium iodides TINCTURE Y N  
73352052001 TRIDERGEL benzalkonium chloride GEL (ML) 0.1 % Y N  
00116030040 BENZ-ALL benzalkonium chloride LIQUID Y N  
68599021404 THERA BODY CLEANSER benzalkonium chloride SOLUTION 0.13 % Y N  
68599021408 THERA BODY CLEANSER benzalkonium chloride SOLUTION 0.13 % Y N  
59088059616 DERMACINRX DIASINC benzalkonium chloride SPRAY 0.13 % Y N  
68599580601 OBSTETRICAL ANTISEPTIC benzalkonium chloride TOWELETTE 0.13 % Y N  
68599580602 OBSTETRICAL ANTISEPTIC benzalkonium chloride TOWELETTE 0.13 % Y N  
68599550101 ANTIBACTERIAL SOAP benzethonium chloride CLEANSER 0.13 % Y N  
68599550102 ANTIBACTERIAL SOAP benzethonium chloride CLEANSER 0.13 % Y N  
68599550103 ANTIBACTERIAL SOAP benzethonium chloride CLEANSER 0.13 % Y N  
68599550104 ANTIBACTERIAL SOAP benzethonium chloride CLEANSER 0.13 % Y N  
68599550201 FOAMING ANTIBACTERIAL SOAP benzethonium chloride FOAM (ML) 0.13 % Y N  
68599550202 FOAMING ANTIBACTERIAL SOAP benzethonium chloride FOAM (ML) 0.13 % Y N  
68599550203 FOAMING ANTIBACTERIAL SOAP benzethonium chloride FOAM (ML) 0.13 % Y N  
00168004231 BORIC ACID boric acid OINT. (G) 10 % Y N  
45802028251 GREEN MOUTHWASH cetylpyridinium/domiphen brom MOUTHWASH Y N  
00116102103 DYNAHEX chlorhexidin/isopropyl alcohol LIQUID 2 %-4 % Y N  
00116102105 DYNAHEX chlorhexidin/isopropyl alcohol LIQUID 2 %-4 % Y N  
00116102106 DYNAHEX chlorhexidin/isopropyl alcohol LIQUID 2 %-4 % Y N  
00116102107 DYNAHEX chlorhexidin/isopropyl alcohol LIQUID 2 %-4 % Y N  
45802003508 CHLORHEXIDINE GLUCONATE chlorhexidin/isopropyl alcohol LIQUID 4 %-4 % Y N  
45802003516 CHLORHEXIDINE GLUCONATE chlorhexidin/isopropyl alcohol LIQUID 4 %-4 % Y N  
45802003517 CHLORHEXIDINE GLUCONATE chlorhexidin/isopropyl alcohol LIQUID 4 %-4 % Y N  
45802003555 CHLORHEXIDINE GLUCONATE chlorhexidin/isopropyl alcohol LIQUID 4 %-4 % Y N  
45802003598 CHLORHEXIDINE GLUCONATE chlorhexidin/isopropyl alcohol LIQUID 4 %-4 % Y N  
00116102104 DYNA-HEX chlorhexidine gluconate LIQUID 2 % Y N  
46122065936 HAND SOAP chlorhexidine gluconate LIQUID 2 % Y N  
46122013734 ANTISEPTIC SKIN CLEANSER chlorhexidine gluconate LIQUID 4 % Y N  
46122013743 ANTISEPTIC SKIN CLEANSER chlorhexidine gluconate LIQUID 4 % Y N  
49348011537 ANTISEPTIC SKIN CLEANSER chlorhexidine gluconate LIQUID 4 % Y N  
68599540001 ANTISEPTIC SKIN CLEANSER chlorhexidine gluconate LIQUID 4 % Y N  
68599540002 ANTISEPTIC SKIN CLEANSER chlorhexidine gluconate LIQUID 4 % Y N  
68599540102 ANTISEPTIC SKIN CLEANSER chlorhexidine gluconate LIQUID 4 % Y N  
68599540103 ANTISEPTIC SKIN CLEANSER chlorhexidine gluconate LIQUID 4 % Y N  
68599540104 ANTISEPTIC SKIN CLEANSER chlorhexidine gluconate LIQUID 4 % Y N  
68599540105 ANTISEPTIC SKIN CLEANSER chlorhexidine gluconate LIQUID 4 % Y N  
68599540106 ANTISEPTIC SKIN CLEANSER chlorhexidine gluconate LIQUID 4 % Y N  
70677122101 ANTISEPTIC SKIN CLEANSER chlorhexidine gluconate LIQUID 4 % Y N  
67618020004 BETASEPT chlorhexidine gluconate LIQUID 4 % Y N  
67618020008 BETASEPT chlorhexidine gluconate LIQUID 4 % Y N  
67618020016 BETASEPT chlorhexidine gluconate LIQUID 4 % Y N  
67618020030 BETASEPT chlorhexidine gluconate LIQUID 4 % Y N  
16571011112 CHLORHEXIDINE GLUCONATE chlorhexidine gluconate LIQUID 4 % Y N  
16571011124 CHLORHEXIDINE GLUCONATE chlorhexidine gluconate LIQUID 4 % Y N  
16571011148 CHLORHEXIDINE GLUCONATE chlorhexidine gluconate LIQUID 4 % Y N  
00116106032 DYNA-HEX chlorhexidine gluconate LIQUID 4 % Y N  
00116106101 DYNA-HEX chlorhexidine gluconate LIQUID 4 % Y N  
00116106104 DYNA-HEX chlorhexidine gluconate LIQUID 4 % Y N  
00116106108 DYNA-HEX chlorhexidine gluconate LIQUID 4 % Y N  
00116106116 DYNA-HEX chlorhexidine gluconate LIQUID 4 % Y N  
00116106118 DYNA-HEX chlorhexidine gluconate LIQUID 4 % Y N  
00116106132 DYNA-HEX chlorhexidine gluconate LIQUID 4 % Y N  
00116106140 DYNA-HEX chlorhexidine gluconate LIQUID 4 % Y N  
68599520401 ANTIMICROBIAL LOTION SOAP chloroxylenol CLEANSER 0.95 % Y N  
68599520402 ANTIMICROBIAL LOTION SOAP chloroxylenol CLEANSER 0.95 % Y N  
68599520403 ANTIMICROBIAL LOTION SOAP chloroxylenol CLEANSER 0.95 % Y N  
68599520404 ANTIMICROBIAL LOTION SOAP chloroxylenol CLEANSER 0.95 % Y N  
68599520405 ANTIMICROBIAL LOTION SOAP chloroxylenol CLEANSER 0.95 % Y N  
45802002905 CLIOQUINOL clioquinol CREAM (G) 3 % Y N  
24385003434 HAND SANITIZER ethyl alcohol GEL (ML) 70 % Y N  
00113087643 ETHYL ALCOHOL ethyl alcohol SOLUTION 70 % Y N  
46122032943 ETHYL ALCOHOL ethyl alcohol SOLUTION 70 % Y N  
70000002001 ETHYL ALCOHOL ethyl alcohol SOLUTION 70 % Y N  
70677122001 ETHYL ALCOHOL ethyl alcohol SOLUTION 70 % Y N  
68599580806 INSTANT HAND SANITIZING ethyl alcohol TOWELETTE 65.9 % Y N  
68599580303 INSTANT HAND SANITIZING ethyl alcohol TOWELETTE 70 % Y N  
68599580304 INSTANT HAND SANITIZING ethyl alcohol TOWELETTE 70 % Y N  
00113007269 ANTISEPTIC eucalyp/me-salicylate/men/thym MOUTHWASH Y N  
00113031869 ANTISEPTIC eucalyp/me-salicylate/men/thym MOUTHWASH Y N  
00113031886 ANTISEPTIC eucalyp/me-salicylate/men/thym MOUTHWASH Y N  
00113066412 ANTISEPTIC eucalyp/me-salicylate/men/thym MOUTHWASH Y N  
00113066421 ANTISEPTIC eucalyp/me-salicylate/men/thym MOUTHWASH Y N  
00113066469 ANTISEPTIC eucalyp/me-salicylate/men/thym MOUTHWASH Y N  
00113066486 ANTISEPTIC eucalyp/me-salicylate/men/thym MOUTHWASH Y N  
00113093286 ANTISEPTIC eucalyp/me-salicylate/men/thym MOUTHWASH Y N  
60219395501 FOSFOMYCIN TROMETHAMINE fosfomycin tromethamine PACKET 3 gram Y N  
60219395503 FOSFOMYCIN TROMETHAMINE fosfomycin tromethamine PACKET 3 gram Y N  
67877074957 FOSFOMYCIN TROMETHAMINE fosfomycin tromethamine PACKET 3 gram Y N  
69097057967 FOSFOMYCIN TROMETHAMINE fosfomycin tromethamine PACKET 3 gram Y N  
70700026894 FOSFOMYCIN TROMETHAMINE fosfomycin tromethamine PACKET 3 gram Y N  
70700026899 FOSFOMYCIN TROMETHAMINE fosfomycin tromethamine PACKET 3 gram Y N  
54092013001 FUROXONE furazolidone TABLET 100 mg Y N  
54092013020 FUROXONE furazolidone TABLET 100 mg Y N  
00338028805 AMINOACETIC ACID glycine urologic solution IRRIG SOLN 1.5 % Y N  
00338028905 AMINOACETIC ACID glycine urologic solution IRRIG SOLN 1.5 % Y N  
00338028908 AMINOACETIC ACID glycine urologic solution IRRIG SOLN 1.5 % Y N  
00338028947 AMINOACETIC ACID glycine urologic solution IRRIG SOLN 1.5 % Y N  
00338029104 AMINOACETIC ACID glycine urologic solution IRRIG SOLN 1.5 % Y N  
00264739060 GLYCINE glycine urologic solution IRRIG SOLN 1.5 % Y N  
00990797408 GLYCINE glycine urologic solution IRRIG SOLN 1.5 % Y N  
00259602008 AQUA GLYCOLIC glycolic acid LIQUID 11 % Y N  
72336081130 CORTI-SAV hydrocortisone/iodoquinol CREAM (G) 1 %-1 % Y N  
46122033443 HYDROGEN PEROXIDE hydrogen peroxide SOLUTION 3 % Y N  
46122077334 HYDROGEN PEROXIDE hydrogen peroxide SOLUTION 3 % Y N  
49348017938 HYDROGEN PEROXIDE hydrogen peroxide SOLUTION 3 % Y N  
68599230102 HYDROGEN PEROXIDE hydrogen peroxide SOLUTION 3 % Y N  
68599230106 HYDROGEN PEROXIDE hydrogen peroxide SOLUTION 3 % Y N  
68599230509 HYDROGEN PEROXIDE hydrogen peroxide SOLUTION 3 % Y N  
70000002201 HYDROGEN PEROXIDE hydrogen peroxide SOLUTION 3 % Y N  
70000002203 HYDROGEN PEROXIDE hydrogen peroxide SOLUTION 3 % Y N  
70000050001 HYDROGEN PEROXIDE hydrogen peroxide SOLUTION 3 % Y N  
70000050002 HYDROGEN PEROXIDE hydrogen peroxide SOLUTION 3 % Y N  
70677124801 HYDROGEN PEROXIDE hydrogen peroxide SOLUTION 3 % Y N  
59365606400 LUGOL'S iodine/potassium iodide SOLUTION 5 %-10 % Y N  
70677120201 IODINE iodine/potassium iodide TINCTURE Y N  
24385021310 IODINE iodine/sodium iodide TINCTURE 2 % Y N  
70000040101 IODINE iodine/sodium iodide TINCTURE 2 % Y N  
70677120401 IODINE iodine/sodium iodide TINCTURE 2 % Y N  
68599863501 ISOPROPYL ALCOHOL isopropyl alcohol MED. SWAB 70 % Y N  
68599863502 ISOPROPYL ALCOHOL isopropyl alcohol MED. SWAB 70 % Y N  
49348097410 ALCOHOL PADS WITH BENZOCAINE isopropyl alcohol/benzocaine MED. PAD 70 %-6 % Y N  
54092031128 FURACIN nitrofurazone CREAM (G) 0.2 % Y N  
54092031016 FURACIN nitrofurazone OINT. (G) 0.2 % Y N  
54092031028 FURACIN nitrofurazone OINT. (G) 0.2 % Y N  
00264220500 PHYSIOLYTE physiological irrig soln no.1 IRRIG SOLN 140 mEq-5 mEq-3 mEq-98 mEq-27 mEq-23 mEq/L Y N  
00990614109 PHYSIOSOL physiological irrig soln no.1 IRRIG SOLN 140 mEq-5 mEq-3 mEq-98 mEq-27 mEq-23 mEq/L Y N  
82098061710 POVIDONE-IODINE povidone-iodine MED. PAD 10 % Y N  
67618019025 BETADINE povidone-iodine MED. SWAB 10 % Y N  
67618019050 BETADINE povidone-iodine MED. SWAB 10 % Y N  
68599863001 POVIDONE-IODINE povidone-iodine MED. SWAB 10 % Y N  
68599863002 POVIDONE-IODINE povidone-iodine MED. SWAB 10 % Y N  
68599863004 POVIDONE-IODINE povidone-iodine MED. SWAB 10 % Y N  
68599863005 POVIDONE-IODINE povidone-iodine MED. SWAB 10 % Y N  
67618018108 BETADINE povidone-iodine MOUTHWASH 0.5 % Y N  
00536127180 FIRST AID ANTISEPTIC povidone-iodine OINT. (G) 10 % Y N  
45802005105 POVIDONE-IODINE povidone-iodine OINT. (G) 10 % Y N  
45802005168 POVIDONE-IODINE povidone-iodine OINT. (G) 10 % Y N  
45802005170 POVIDONE-IODINE povidone-iodine PACKET 10 % Y N  
45802008255 POVIDONE-IODINE povidone-iodine SOLUTION 0.3 % Y N  
67618015001 BETADINE povidone-iodine SOLUTION 10 % Y N  
67618015004 BETADINE povidone-iodine SOLUTION 10 % Y N  
67618015005 BETADINE povidone-iodine SOLUTION 10 % Y N  
67618015009 BETADINE povidone-iodine SOLUTION 10 % Y N  
67618015017 BETADINE povidone-iodine SOLUTION 10 % Y N  
67618015018 BETADINE povidone-iodine SOLUTION 10 % Y N  
00254085355 POVIDONE-IODINE povidone-iodine SOLUTION 10 % Y N  
00254085358 POVIDONE-IODINE povidone-iodine SOLUTION 10 % Y N  
00254085362 POVIDONE-IODINE povidone-iodine SOLUTION 10 % Y N  
00904110309 POVIDONE-IODINE povidone-iodine SOLUTION 10 % Y N  
24385005355 POVIDONE-IODINE povidone-iodine SOLUTION 10 % Y N  
45802005218 POVIDONE-IODINE povidone-iodine SOLUTION 10 % Y N  
70000006001 POVIDONE-IODINE povidone-iodine SOLUTION 10 % Y N  
70677120801 POVIDONE-IODINE povidone-iodine SOLUTION 10 % Y N  
82429020216 POVIDONE-IODINE povidone-iodine SOLUTION 10 % Y N  
68599350001 PVP PREP povidone-iodine SOLUTION 10 % Y N  
68599350005 PVP PREP povidone-iodine SOLUTION 10 % Y N  
68599350201 PVP PREP povidone-iodine SOLUTION 10 % Y N  
68599350205 PVP PREP povidone-iodine SOLUTION 10 % Y N  
00065041130 BETADINE povidone-iodine SOLUTION 5 % Y N  
67618015101 BETADINE povidone-iodine SOLUTION 7.5 % Y N  
67618015104 BETADINE povidone-iodine SOLUTION 7.5 % Y N  
67618016003 BETADINE povidone-iodine SPRAY 5 % Y N  
00093961413 SILVER NITRATE silver nitrate SOLUTION 0.5 % Y N  
64950037896 SILVER NITRATE silver nitrate SOLUTION 0.5 % Y N  
00264220100 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00264220110 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00264738850 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00264738860 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338004727 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338004729 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338004744 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338004746 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338004747 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338004802 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338004803 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338004804 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338005047 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338005144 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338011001 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00338011004 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00990613803 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00990613822 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00990713809 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00990713836 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00990797205 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00990797207 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
00990797208 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
65219050201 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
65219050210 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
65219050402 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
65219050420 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
65219050603 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
65219050630 SODIUM CHLORIDE sodium chloride irrig solution IRRIG SOLN 0.9 % Y N  
39328006325 HYSEPT sodium hypochlorite SOLUTION 0.25 % Y N  
39328006250 HYSEPT sodium hypochlorite SOLUTION 0.5 % Y N  
00338028704 UROLOGIC SOLUTION G urologic solution-G IRRIG SOLN 3.24 gram-380 mg-430 mg/100 mL Y N  
00338028744 UROLOGIC SOLUTION G urologic solution-G IRRIG SOLN 3.24 gram-380 mg-430 mg/100 mL Y N  
00264210100 WATER water for irrigation,sterile IRRIG SOLN Y N  
00264210110 WATER water for irrigation,sterile IRRIG SOLN Y N  
00264738650 WATER water for irrigation,sterile IRRIG SOLN Y N  
00264738660 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000204 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000205 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000302 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000303 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000304 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000305 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000344 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000346 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000347 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000402 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000403 WATER water for irrigation,sterile IRRIG SOLN Y N  
00338000404 WATER water for irrigation,sterile IRRIG SOLN Y N  
00990613903 WATER water for irrigation,sterile IRRIG SOLN Y N  
00990613922 WATER water for irrigation,sterile IRRIG SOLN Y N  
00990713909 WATER water for irrigation,sterile IRRIG SOLN Y N  
00990713936 WATER water for irrigation,sterile IRRIG SOLN Y N  
00990797305 WATER water for irrigation,sterile IRRIG SOLN Y N  
00990797307 WATER water for irrigation,sterile IRRIG SOLN Y N  
00990797308 WATER water for irrigation,sterile IRRIG SOLN Y N  
65219049903 WATER water for irrigation,sterile IRRIG SOLN Y N  
65219049930 WATER water for irrigation,sterile IRRIG SOLN Y N  
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