Analgesics, Topical

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Drug Use Review Documents

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
CAPSAICIN ZOSTRIX-HP CREAM (G) Y    
CAPSAICIN ZOSTRIX HP FOOT CREAM (G) Y    
CAPSAICIN ZOSTRIX HP CREAM (G) Y    
CAPSAICIN ZOSTRIX CREAM (G) Y    
CAPSAICIN THERAGEN CREAM (G) Y    
CAPSAICIN MEDI-GEN CREAM (G) Y    
CAPSAICIN HIGH POTENCY CAPSAICIN CREAM (G) Y    
CAPSAICIN CAPZASIN-P CREAM (G) Y    
CAPSAICIN CAPZASIN-HP CREAM (G) Y    
CAPSAICIN CAPSAICIN-HP CREAM (G) Y    
CAPSAICIN CAPSAICIN CREAM (G) Y    
CAPSAICIN ARTHRITIS PAIN RELIEF CREAM (G) Y    
CAPSAICIN ARTHRITIS PAIN RELIEVING CREAM (G) Y    
CAPSAICIN CAPSAICIN CREAM (G) Y    
DICLOFENAC SODIUM DICLOFENAC SODIUM DROPS Y 1.5 % Require PA  
CAPSAICIN CAPSAICIN LIQUID N    
CAPSAICIN/ME-SALICYLATE/MENTH ZIKS CREAM (G) N    
CAPSAICIN/SKIN CLEANSER QUTENZA KIT N    
DICLOFENAC EPOLAMINE FLECTOR PATCH TD12 N    
DICLOFENAC SODIUM DICLOFENAC SODIUM GEL (GRAM) N    
DICLOFENAC SODIUM VOLTAREN GEL (GRAM) N    
DICLOFENAC SODIUM PENNSAID SOL MD PMP N    
LIDOCAINE LIDODERM ADH. PATCH N PA Document  
LIDOCAINE LIDOCAINE ADH. PATCH N PA Document  
LIDOCAINE LIDOCAINE CREAM (G) N    
LIDOCAINE LIDOCAINE OINT. (G) N