Topical Nasal and Otic

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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
Current Drug Use Criteria New Drug Evaluation
acetic acid ACETIC ACID SOLUTION    
carbamide peroxide EARWAX TREATMENT DROPS DROPS    
carbamide peroxide EAR WAX REMOVAL DROPS    
carbamide peroxide EAR SYSTEM DROPS    
carbamide peroxide EAR DROPS DROPS    
fluocinolone acetonide oil FLUOCINOLONE ACETONIDE OIL DROPS    
fluocinolone acetonide oil DERMOTIC DROPS    
hydrocortisone/acetic acid HYDROCORTISONE-ACETIC ACID DROPS    
hydrocortisone/acetic acid ACETASOL HC DROPS    
isopropyl alcohol in glycerin SWIM EAR DROPS