Misc Analgesics

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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.
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
acetaminophen/d-brompheniramin DOLOGESIC-DF TABLET N    
acetaminophen/d-brompheniramin DOLOGESIC TABLET N    
acetaminophen/diphenhydramine PAIN RELIEVER PM TABLET N    
acetaminophen/diphenhydramine EXT STR PAIN RELIEF/SLEEP TABLET N    
acetaminophen/diphenhydramine ACETAMINOPHEN PM TABLET N    
acetaminophen/diphenhydramine PAIN RELIEF PM TABLET N    
aspirin/acetaminophn/diphenhyd PAIN RELIEF PM TABLET N    
butalb/acetaminophen/caffeine BUTALBITAL-ACETAMINOPHEN-CAFFE CAPSULE N    
butalb/acetaminophen/caffeine ESGIC CAPSULE N    
butalb/acetaminophen/caffeine ZEBUTAL CAPSULE N    
butalb/acetaminophen/caffeine FIORICET CAPSULE N    
butalb/acetaminophen/caffeine BUTALBITAL-ACETAMINOPHEN-CAFFE TABLET N    
butalb/acetaminophen/caffeine QUALA-CET TABLET N    
butalb/acetaminophen/caffeine ESGIC TABLET N    
butalbital/acetaminophen BUTALBITAL-ACETAMINOPHEN CAPSULE N    
butalbital/acetaminophen REPAN-CF TABLET N    
butalbital/acetaminophen BUTALBITAL-ACETAMINOPHEN TABLET N    
butalbital/acetaminophen BUPAP TABLET N    
butalbital/aspirin/caffeine BUTALBITAL-ASPIRIN-CAFFEINE CAPSULE N    
acetaminophen MAPAP CAPSULE    
acetaminophen INFANT'S NON-ASPIRIN DROPS    
acetaminophen INFANT DROPS DROPS    
acetaminophen INFANT'S NON-ASPIRIN DROPS SUSP    
acetaminophen ACETAMINOPHEN ELIXIR    
acetaminophen CHILDREN'S ACETAMINOPHEN LIQUID    
acetaminophen ACETAMINOPHEN LIQUID    
acetaminophen SILAPAP LIQUID    
acetaminophen REDUTEMP LIQUID    
acetaminophen M-PAP LIQUID    
acetaminophen ED-APAP LIQUID    
acetaminophen MAPAP LIQUID    
acetaminophen CHILDREN'S PAIN RELIEF ORAL SUSP    
acetaminophen CHILDREN'S ACETAMINOPHEN ORAL SUSP    
acetaminophen CHILDREN'S PAIN RELIEVER ORAL SUSP    
acetaminophen ACETAMINOPHEN ORAL SUSP    
acetaminophen CHILDREN'S PAIN-FEVER ORAL SUSP    
acetaminophen INFANTS' ACETAMINOPHEN ORAL SUSP    
acetaminophen INFANTS' PAIN-FEVER ORAL SUSP    
acetaminophen MAPAP CHILDREN'S ORAL SUSP    
acetaminophen INFANT PAIN-FEVER ORAL SUSP    
acetaminophen ACETAMINOPHEN PIGGYBACK    
acetaminophen ACETAMINOPHEN SOLUTION    
acetaminophen ACETAMINOPHEN SUPP.RECT    
acetaminophen PAIN RELIEVER SUPP.RECT    
acetaminophen FEVERALL SUPP.RECT    
acetaminophen ACETAMINOPHEN SYRINGE    
acetaminophen CHILDREN'S PAIN RELIEF TAB CHEW    
acetaminophen CHILDREN'S MAPAP TAB CHEW    
acetaminophen CHILDREN'S ACETAMINOPHEN TAB CHEW    
acetaminophen PAIN RELIEVER JUNIOR STRENGTH TAB CHEW    
acetaminophen ACETAMINOPHEN TABLET    
acetaminophen PAIN RELIEVER TABLET    
acetaminophen PAIN RELIEF EXTRA STRENGTH TABLET    
acetaminophen PAIN RELIEF TABLET    
acetaminophen ARTHRITIS PAIN RELIEVER TABLET ER    
acetaminophen ARTHRITIS PAIN RELIEF TABLET ER    
acetaminophen ARTHRITIS PAIN TABLET ER    
acetaminophen ACETAMINOPHEN ER TABLET ER    
acetaminophen 8HR MUSCLE ACHES-PAIN TABLET ER    
acetaminophen 8HR ARTHRITIS PAIN TABLET ER    
acetaminophen 8 HOUR PAIN RELIEF TABLET ER    
acetaminophen 8 HOUR ACETAMINOPHEN TABLET ER    
acetaminophen PAIN RELIEVER TABLET ER    
acetaminophen PAIN RELIEF TABLET ER    
acetaminophen ACETAMINOPHEN VIAL    
acetaminophen/caffeine TENSION HEADACHE TABLET    
acetaminophen/chlorpheniramine CORICIDIN HBP COLD AND FLU TABLET    
acetaminophen/diphenhydramine ALLERGY SEVERE TABLET    
acetaminophen/diphenhydramine PAIN RELIEVER TABLET SEQ    
acetaminophen/phenyltoloxamine CONTRAGESIC TABLET    
acetaminophen/pyrilam/pamabrom MENSTRUAL RELIEF TABLET    
ASA/acetaminophen/caffeine/cal SUPAC TABLET    
aspirin ASPIRIN SUPP.RECT    
aspirin/acetaminophen/caffeine MIGRAINE RELIEF TABLET    
aspirin/acetaminophen/caffeine PAIN RELIEVER PLUS TABLET    
aspirin/acetaminophen/caffeine MIGRAINE FORMULA TABLET    
aspirin/acetaminophen/caffeine HEADACHE RELIEF TABLET    
aspirin/acetaminophen/caffeine HEADACHE PAIN TABLET    
aspirin/acetaminophen/caffeine EXTRA PAIN RELIEF TABLET    
aspirin/caffeine AA & C TABLET    
aspirin/calcium carb/magnesium TRI-BUFFERED ASPIRIN TABLET    
aspirin/calcium carb/magnesium BUFFERED ASPIRIN TABLET    
aspirin/calcium/mag/aluminum ASPRIDROX TABLET    
aspirin/sod bicarb/citric acid EFFERVESCENT ANTACID-PAIN RLF TABLET EFF    
aspirin/sod bicarb/citric acid EFFERVESCENT PAIN RELIEF TABLET EFF    
choline salicyl/mag salicylate TRICOSAL TABLET    
clonidine HCl/PF DURACLON VIAL    
clonidine HCl/PF CLONIDINE HCL VIAL    
dihydroergotamine mesylate DIHYDROERGOTAMINE MESYLATE AMPUL    
dihydroergotamine mesylate DIHYDROERGOTAMINE MESYLATE SPRAY/PUMP    
dihydroergotamine mesylate MIGRANAL SPRAY/PUMP    
dimethyl sulfoxide RIMSO-50 SOLUTION    
ibuprofen/diphenhydramine cit IBUPROFEN PM TABLET    
ketorolac tromethamine TORADOL CARTRIDGE    
ketorolac tromethamine KETOROLAC TROMETHAMINE CARTRIDGE    
ketorolac tromethamine KETOROLAC TROMETHAMINE SYRINGE    
ketorolac tromethamine KETOROLAC TROMETHAMINE VIAL    
magnesium salicylate BACKACHE PAIN RELIEF TABLET    
pentosan polysulfate sodium ELMIRON CAPSULE    
sal-amide/acetaminophen/p-tlox CETAZONE-T TABLET    
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