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 CAPSICUM OLEORESIN CREAM (G) Y    
capsaicin DOUBLE CAP CREAM (G) Y    
capsaicin CAPZASIN-P CREAM (G) Y    
capsaicin CAPSAICIN HP CREAM (G) Y    
capsaicin DOLORAC CREAM (G) Y    
capsaicin CAPZASIN-HP CREAM (G) Y    
capsaicin HIGH POTENCY CAPSAICIN CREAM (G) Y    
capsaicin MUSCLE RELIEF CREAM (G) Y    
capsaicin RECAPSIN CREAM (G) Y    
capsaicin NUPRIN ARTHRITIS CREAM (G) Y    
capsaicin MEDI-GEN CREAM (G) Y    
capsaicin CAPREX + CREAM (G) Y    
capsaicin CAPREX CREAM (G) Y    
capsaicin ARTHRITIS PAIN RELIEF CREAM (G) Y    
capsaicin ARTHRITIS FORMULA CAPSAICIN CREAM (G) Y    
capsaicin CAPSAICIN CREAM (G) Y    
capsaicin ARTHRITIS PAIN RELIEVING CREAM (G) Y    
capsaicin THERAGEN CREAM (G) Y    
capsaicin CAPSAICIN-HP CREAM (G) Y    
capsaicin TRIXAICIN CREAM (G) Y    
capsaicin ZOSTRIX CREAM (G) Y    
capsaicin ZOSTRIX DIABETIC CREAM (G) Y    
capsaicin ZOSTRIX HP CREAM (G) Y    
capsaicin ZOSTRIX HP FOOT CREAM (G) Y    
capsaicin ZOSTRIX NEUROPATHY CREAM (G) Y    
capsaicin ZOSTRIX-HP 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