General Actibacterial, Antibacterials

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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
ALCOHOL ANTISEPTIC PADS IV PREP WIPES MED. PAD    
ALCOHOL ANTISEPTIC PADS ALCOHOL SWAB MED. PAD    
ALCOHOL ANTISEPTIC PADS ALCOHOL PREP PADS MED. PAD    
AMMONIUM AND POTASSIUM IODIDES IODIDES TINCTURE    
BENZALKONIUM CHLORIDE REMEDY LIQUID    
BENZETHONIUM CHLORIDE SECURA MOISTURIZING CLEANSER    
BENZETHONIUM CHLORIDE SECURA CLEANSER    
BENZETHONIUM CHLORIDE BEDSIDE-CARE PERINEAL CLEANSER    
BENZETHONIUM CHLORIDE DERMAL WOUND CLEANSER CLEANSER    
BENZETHONIUM CHLORIDE SECURA FOAM (ML)    
CHLORHEXIDINE GLUCONATE BETASEPT LIQUID    
CHLORHEXIDINE GLUCONATE ANTISEPTIC SKIN CLEANSER LIQUID    
ETHYL ALCOHOL ISAGEL NO RINSE GEL (ML)    
ETHYL ALCOHOL HAND SANITIZER GEL (ML)    
ETHYL ALCOHOL ETHYL ALCOHOL SOLUTION    
FORMALDEHYDE FORMALDEHYDE SOL W/APPL    
FOSFOMYCIN TROMETHAMINE MONUROL PACKET    
GLYCINE UROLOGIC SOLUTION GLYCINE IRRIG SOLN    
GLYCINE UROLOGIC SOLUTION AMINOACETIC ACID IRRIG SOLN    
HYDROCORTISONE/IODOQUINOL HYDROCORTISONE-IODOQUINOL CREAM (G)    
HYDROGEN PEROXIDE HYDROGEN PEROXIDE SOLUTION    
IODINE/SODIUM IODIDE IODINE TINCTURE    
METHYLBENZETHONIUM CHLORIDE BEDSIDE-CARE SOLUTION    
PHENOL CASTELLANI PAINT MODIFIED LIQUID    
PHYSIOLOGICAL IRRIG SOLN NO.1 PHYSIOLYTE IRRIG SOLN    
PHYSIOLOGICAL IRRIG SOLN NO.1 PHYSIOSOL IRRIG SOLN    
POVIDONE-IODINE BETADINE CLEANSER    
POVIDONE-IODINE BETADINE MED. SWAB    
POVIDONE-IODINE POVIDONE-IODINE OINT. (G)    
POVIDONE-IODINE POVIDONE-IODINE SOLUTION    
POVIDONE-IODINE BETADINE SOLUTION    
POVIDONE-IODINE BETADINE SPRAY    
SILVER NITRATE SILVER NITRATE SOLUTION    
SODIUM CHLORIDE IRRIG SOLUTION SODIUM CHLORIDE IRRIG SOLN    
TRICLOSAN GENTLE RAIN LIQ. SOAP    
WATER FOR IRRIGATION,STERILE WATER IRRIG SOLN