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 BACITRAYCIN PLUS OINT. (G) Y    
BACITRACIN BACITRACIN OINT. (G) Y 500 unit/gram Require PA  
BACITRACIN ZINC ANTIBIOTIC 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/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 DOUBLE ANTIBIOTIC OINT. (G) Y    
BACITRACIN ZINC/POLYMYXIN B POLY BACITRACIN 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 DOUBLE 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 FIRST AID ANTIBIOTIC OINT. (G) Y    
NEOMYCIN/BACITRACIN/POLYMYXINB NEOSPORIN OINT. (G) Y    
NEOMYCIN/BACITRACIN/POLYMYXINB TRIPLE ANTI OINT. (G) Y    
NEOMYCIN/BACITRACIN/POLYMYXINB TRIPLE ANTIBIOTIC OINT. (G) Y    
NEOMYCIN/BACITRACIN/POLYMYXINB ANTIBIOTIC OINT. (G) Y    
BACITRACIN BACITRACIN PACKET N    
BACITRACIN ZINC BACITRACIN ZINC PACKET N    
CLINDAMYCIN PHOS/SKIN CLNSR 19 CLINDACIN ETZ KIT N    
CLINDAMYCIN PHOS/SKIN CLNSR 19 CLINDACIN PAC KIT N    
CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE FOAM N    
CLINDAMYCIN PHOSPHATE EVOCLIN FOAM N    
CLINDAMYCIN PHOSPHATE CLEOCIN T GEL (GRAM) N    
CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE GEL (GRAM) N    
CLINDAMYCIN PHOSPHATE CLEOCIN T LOTION N    
CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE LOTION N    
CLINDAMYCIN PHOSPHATE CLINDACIN ETZ MED. SWAB N    
CLINDAMYCIN PHOSPHATE CLINDACIN P MED. SWAB N    
CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE MED. SWAB N    
CLINDAMYCIN PHOSPHATE CLEOCIN T MED. SWAB N    
CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE SOLUTION N    
ERYTHROMYCIN BASE/ETHANOL ERYTHROMYCIN GEL (GRAM) N    
ERYTHROMYCIN BASE/ETHANOL ERYGEL GEL (GRAM) N    
ERYTHROMYCIN BASE/ETHANOL ERYTHROMYCIN MED. SWAB N    
ERYTHROMYCIN BASE/ETHANOL ERY 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 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 PLUS OINT. (G) N    
NEOMYCN/BACITRC/POLYMYX/PRAMOX TRIPLE ANTIBIOTIC EXTRA OINT. (G) N