Antibiotics, 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 but eligible patients will encounter a co-pay at the pharmacy.
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
bacitracin BACITRACIN OINT. (G) Y 500 unit/gram Require PA  
bacitracin BACITRAYCIN PLUS OINT. (G) Y    
bacitracin BACTERICIN OINT. (G) Y    
bacitracin FIRST AID BACITRACIN OINT. (G) Y    
bacitracin HM BACITRACIN OINT. (G) Y    
bacitracin zinc BACITRACIN ZINC OINT. (G) Y    
bacitracin zinc BACITRACIN ZINC OINT. (G) Y    
bacitracin zinc ANTIBIOTIC OINT. (G) Y    
bacitracin zinc ANTIBIOTIC OINT. (G) Y    
bacitracin zinc/polymyxin B POLY BACITRACIN OINT. (G) Y    
bacitracin zinc/polymyxin B DOUBLE ANTIBIOTIC OINT. (G) Y    
bacitracin zinc/polymyxin B POLY BACITRACIN OINT. (G) Y    
bacitracin zinc/polymyxin B WAL-SPORIN OINT. (G) Y    
bacitracin zinc/polymyxin B BETADINE OINT. (G) Y    
bacitracin zinc/polymyxin B DOUBLE ANTIBIOTIC OINT. (G) Y    
bacitracin/polymyxin B sulfate DOUBLE ANTIBIOTIC OINT. (G) Y    
bacitracin/polymyxin B sulfate POLYMYXIN OINT. (G) Y    
bacitracin/polymyxin B sulfate BACITRACIN/POLYMYXIN OINT. (G) Y    
bacitracin/polymyxin B sulfate BACITRACIN-POLYMYXIN OINT. (G) Y    
bacitracin/polymyxin B sulfate DOUBLE ANTIBIOTIC OINT. (G) Y    
bacitracin/polymyxin B sulfate POLY BACITRACIN OINT. (G) Y    
bacitracin/polymyxin B sulfate POLYSPORIN OINT. (G) Y    
bacitracin/polymyxin B sulfate MULTI-ANTIBIOTIC OINT. (G) Y    
gentamicin sulfate GENTAMICIN SULFATE CREAM (G) Y    
mupirocin CENTANY OINT. (G) Y    
mupirocin MUPIROCIN OINT. (G) Y    
neomycin/bacitracin/polymyxinB TRIPLE ANTIBIOTIC OINT. (G) Y    
neomycin/bacitracin/polymyxinB TRISPORIC OINT. (G) Y    
neomycin/bacitracin/polymyxinB ALBA-3 OINT. (G) Y    
neomycin/bacitracin/polymyxinB ANTIBIOTIC OINT. (G) Y    
neomycin/bacitracin/polymyxinB BACTINE TRIPLE ANTIBIOTIC OINT. (G) Y    
neomycin/bacitracin/polymyxinB FIRST AID ANTIBIOTIC OINT. (G) Y    
neomycin/bacitracin/polymyxinB HM TRIPLE ANTIBIOTIC OINT. (G) Y    
neomycin/bacitracin/polymyxinB NEOMIXIN OINT. (G) Y    
neomycin/bacitracin/polymyxinB NEOSPORIN OINT. (G) Y    
neomycin/bacitracin/polymyxinB NEOMYCIN/BACITRACIN/POLYMYXIN OINT. (G) Y    
neomycin/bacitracin/polymyxinB TRIPLE ANTIBIOTIC OINT. (G) Y    
neomycin/bacitracin/polymyxinB TRIPLE ANTI OINT. (G) Y    
neomycin/bacitracin/polymyxinB NEOPORACIN OINT. (G) Y    
neomycin/bacitracin/polymyxinB TRIBIOTIC OINT. (G) Y    
bacitracin BACITRACIN PACKET N    
bacitracin zinc BACITRACIN ZINC PACKET N    
clindamycin phos/skin clnsr 19 CLINDACIN PAC KIT N    
clindamycin phos/skin clnsr 19 CLINDACIN ETZ KIT N    
clindamycin phosphate CLINDAMYCIN PHOSPHATE FOAM N    
clindamycin phosphate EVOCLIN FOAM N    
clindamycin phosphate CLINDAMYCIN PHOSPHATE GEL (GRAM) N    
clindamycin phosphate CLEOCIN T GEL (GRAM) N    
clindamycin phosphate CLEOCIN T LOTION N    
clindamycin phosphate CLINDAMYCIN PHOSPHATE LOTION N    
clindamycin phosphate CLINDAMYCIN PHOSPHATE MED. SWAB N    
clindamycin phosphate CLINDACIN P MED. SWAB N    
clindamycin phosphate CLEOCIN T MED. SWAB N    
clindamycin phosphate CLINDACIN ETZ MED. SWAB N    
clindamycin phosphate CLINDAMYCIN PHOSPHATE SOLUTION N    
erythromycin base/ethanol ERYGEL GEL (GRAM) N    
erythromycin base/ethanol ERYTHROMYCIN GEL (GRAM) N    
erythromycin base/ethanol ERY MED. SWAB N    
erythromycin base/ethanol ERYTHROMYCIN MED. SWAB N    
erythromycin base/ethanol ERYTHROMYCIN SOLUTION N    
erythromycin/benzoyl peroxide ERYTHROMYCIN-BENZOYL PEROXIDE GEL (GRAM) N    
erythromycin/benzoyl peroxide BENZAMYCIN GEL (GRAM) N    
gentamicin sulfate GENTAMICIN SULFATE OINT. (G) N    
mupirocin CENTANY AT KIT N    
mupirocin MUPIROCIN OIN/PF APP N    
mupirocin calcium MUPIROCIN CREAM (G) N    
neomycin/bacitracin/polymyxinB TRIPLE ANTIBIOTIC OINT PACK N    
neomycin/polymyxin B/pramoxine ANTIBIOTIC PLUS CREAM (G) N    
neomycn/bacitrc/polymyx/pramox TRIPLE ANTIBIOTIC EXTRA OINT. (G) N    
neomycn/bacitrc/polymyx/pramox TRIPLE ANTIBIOTIC PLUS OINT. (G) N