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 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
sumatriptan su/menthol/camphor MIGRANOW KIT GEL-TB Y    
acetaminophen/d-brompheniramin DOLOGESIC TABLET N    
acetaminophen/d-brompheniramin DOLOGESIC-DF TABLET N    
acetaminophen/diphenhydramine HEADACHE PM FORMULA TABLET N    
acetaminophen/diphenhydramine HEADACHE RELIEF PM TABLET N    
acetaminophen/diphenhydramine MAPAP PM TABLET N    
acetaminophen/diphenhydramine NON-ASPIRIN PM TABLET N    
acetaminophen/diphenhydramine PAIN RELIEF PM TABLET N    
acetaminophen/diphenhydramine PAIN RELIEVER PM TABLET N    
acetaminophen/diphenhydramine ACETAMINOPHEN-DIPHENHYDRAMINE TABLET N    
acetaminophen/diphenhydramine ACETAMINOPHEN PM TABLET N    
acetaminophen/diphenhydramine EXT STR PAIN RELIEF/SLEEP TABLET N    
acetaminophen/diphenhydramine HEADACHE PM TABLET N    
brompheniramine/acetaminophen STAFLEX TABLET N    
butalb/acetaminophen/caffeine ESGIC CAPSULE N    
butalb/acetaminophen/caffeine FIORICET CAPSULE N    
butalb/acetaminophen/caffeine ZEBUTAL CAPSULE N    
butalb/acetaminophen/caffeine CAPACET CAPSULE N    
butalb/acetaminophen/caffeine BUTALBITAL-ACETAMINOPHEN-CAFFE CAPSULE N    
butalb/acetaminophen/caffeine VANATOL LQ SOLUTION N    
butalb/acetaminophen/caffeine VANATOL S SOLUTION N    
butalb/acetaminophen/caffeine ESGIC TABLET N    
butalb/acetaminophen/caffeine AMERICET TABLET N    
butalb/acetaminophen/caffeine QUALA-CET TABLET N    
butalb/acetaminophen/caffeine BUTALBITAL-ACETAMINOPHEN-CAFFE TABLET N    
butalbital/acetaminophen BUTALBITAL-ACETAMINOPHEN CAPSULE N    
butalbital/acetaminophen ALLZITAL TABLET N    
butalbital/acetaminophen BUPAP TABLET N    
butalbital/acetaminophen BUTALBITAL-ACETAMINOPHEN TABLET N    
butalbital/acetaminophen MARTEN-TAB TABLET N    
butalbital/acetaminophen REPAN-CF TABLET N    
butalbital/aspirin/caffeine FIORINAL CAPSULE N    
butalbital/aspirin/caffeine BUTALBITAL-ASPIRIN-CAFFEINE CAPSULE N    
butalbital/aspirin/caffeine BUTALBITAL-ASPIRIN-CAFFEINE TABLET N    
acetaminophen PAIN RELIEVER CAPSULE    
acetaminophen MAPAP CAPSULE    
acetaminophen ACETAMINOPHEN CAPSULE    
acetaminophen INFANT'S NON-ASPIRIN DROPS    
acetaminophen INFANT DROPS DROPS    
acetaminophen INFANT'S PAIN RELIEF DROPS SUSP    
acetaminophen INFANT'S NON-ASPIRIN DROPS SUSP    
acetaminophen ACETAMINOPHEN ELIXIR    
acetaminophen MAPAP LIQUID    
acetaminophen ACETAMINOPHEN LIQUID    
acetaminophen ED-APAP LIQUID    
acetaminophen CHILDREN'S PAIN AND FEVER LIQUID    
acetaminophen CHILDREN'S SILAPAP LIQUID    
acetaminophen INFANTS' PAIN-FEVER ORAL SUSP    
acetaminophen MAPAP CHILDREN'S ORAL SUSP    
acetaminophen MAPAP ORAL SUSP    
acetaminophen INFANTS' PAIN RELIEF ORAL SUSP    
acetaminophen CHILDREN'S PAIN RELIEVER ORAL SUSP    
acetaminophen INFANT PAIN-FEVER ORAL SUSP    
acetaminophen CHILDREN'S PAIN-FEVER ORAL SUSP    
acetaminophen CHILDREN'S PAIN RELIEF ORAL SUSP    
acetaminophen CHILDREN'S ACETAMINOPHEN ORAL SUSP    
acetaminophen ACETAMINOPHEN SOLUTION    
acetaminophen PAIN RELIEVER SUPP.RECT    
acetaminophen ACETAMINOPHEN SUPP.RECT    
acetaminophen ACEPHEN SUPP.RECT    
acetaminophen FEVERALL SUPP.RECT    
acetaminophen CHILDREN'S ACETAMINOPHEN SYRINGE    
acetaminophen NON-ASPIRIN TAB CHEW    
acetaminophen MAPAP TAB CHEW    
acetaminophen CHILDREN'S TACTINAL TAB CHEW    
acetaminophen PAIN RELIEVER JUNIOR STRENGTH TAB CHEW    
acetaminophen CHILDREN'S PAIN & FEVER TAB CHEW    
acetaminophen CHILDREN'S MAPAP TAB CHEW    
acetaminophen CHILDREN'S ACETAMINOPHEN TAB CHEW    
acetaminophen JUNIOR MAPAP TAB RAPDIS    
acetaminophen JR. STR NON-ASPIRIN PAIN TAB RAPDIS    
acetaminophen CHILDREN'S MAPAP TAB RAPDIS    
acetaminophen CHILDREN'S EASY-MELTS TAB RAPDIS    
acetaminophen NON-ASPIRIN EXTRA STRENGTH TABLET    
acetaminophen PAIN RELIEVER TABLET    
acetaminophen PAIN RELIEF EXTRA STRENGTH TABLET    
acetaminophen PAIN RELIEF TABLET    
acetaminophen NON-ASPIRIN PAIN RELIEF TABLET    
acetaminophen MAPAP TABLET    
acetaminophen PAIN & FEVER TABLET    
acetaminophen TACTINAL TABLET    
acetaminophen PHARBETOL TABLET    
acetaminophen ACETAMINOPHEN TABLET    
acetaminophen EXTRA STRENGTH NON-ASPIRIN TABLET    
acetaminophen PAIN RELIEF TABLET ER    
acetaminophen MAPAP ARTHRITIS PAIN TABLET ER    
acetaminophen PAIN RELIEVER TABLET ER    
acetaminophen 8HR MUSCLE ACHES-PAIN TABLET ER    
acetaminophen ACETAMINOPHEN 8 HOUR TABLET ER    
acetaminophen ARTHRITIS PAIN TABLET ER    
acetaminophen ARTHRITIS PAIN RELIEF TABLET ER    
acetaminophen 8HR ARTHRITIS PAIN TABLET ER    
acetaminophen 8 HOUR PAIN RELIEF TABLET ER    
acetaminophen 8 HOUR TABLET ER    
acetaminophen ACETAMINOPHEN ER TABLET ER    
acetaminophen ARTHRITIS PAIN RELIEVER TABLET ER    
acetaminophen/caffeine TENSION HEADACHE TABLET    
acetaminophen/caffeine EXCEDRIN TENSION HEADACHE TABLET    
acetaminophen/chlorpheniramine CORICIDIN HBP TABLET    
acetaminophen/diphenhydramine ALLERGY SEVERE TABLET    
acetaminophen/diphenhydramine ACETA-GESIC TABLET    
acetaminophen/diphenhydramine PAIN RELIEVER TABLET SEQ    
acetaminophen/pamabrom WOMEN'S MENSTRUAL RELIEF TABLET    
acetaminophen/phenyltoloxamine CONTRAGESIC TABLET    
acetaminophen/pyrilam/pamabrom MENSTRUAL RELIEF TABLET    
acetaminophen/pyrilamine/caff MENSTRUAL RELIEF TABLET    
ASA/acetaminophen/caffeine/cal SUPAC TABLET    
ASA/calcium carb/mag/aluminum ASCRIPTIN TABLET    
ASA/calcium carb/mag/aluminum ASPRIDROX TABLET    
ASA/calcium carb/mag/aluminum ASCRIPTIN MAXIMUM STRENGTH TABLET    
aspirin ASPIRIN SUPP.RECT    
aspirin ASPIRIN EC TABLET DR    
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/acetaminophen/caffeine EXCEDRIN MIGRAINE TABLET    
aspirin/acetaminophen/caffeine EXCEDRIN EXTRA STRENGTH TABLET    
aspirin/caffeine AA & C TABLET    
aspirin/calcium carbonate/mag TRI-BUFFERED ASPIRIN TABLET    
aspirin/sod bicarb/citric acid EFFERVESCENT PAIN RELIEF TABLET EFF    
clonidine HCl/PF DURACLON VIAL    
clonidine HCl/PF CLONIDINE HCL VIAL    
dihydroergotamine mesylate DIHYDROERGOTAMINE MESYLATE AMPUL    
dihydroergotamine mesylate D.H.E.45 AMPUL    
dihydroergotamine mesylate MIGRANAL SPRAY/PUMP    
dihydroergotamine mesylate DIHYDROERGOTAMINE MESYLATE SPRAY/PUMP    
dihydroergotamine mesylate DIHYDROERGOTAMINE MESYLATE VIAL    
dimethyl sulfoxide RIMSO-50 SOLUTION    
ergotamine tartrate ERGOMAR TAB SUBL    
ergotamine tartrate/caffeine MIGERGOT SUPP.RECT    
ergotamine tartrate/caffeine CAFERGOT TABLET    
ibuprofen/diphenhydramine cit IBUPROFEN PM TABLET    
ibuprofen/diphenhydramine cit ADVIL PM TABLET    
ibuprofen/diphenhydramine HCl ADVIL PM CAPSULE    
isomethept/dichlphn/acetaminop ISOMETHEPT-DICHLORALP-ACETAMIN CAPSULE    
isomethepten/caf/acetaminophen ISOMETHEPT-CAFF-ACETAMINOPHEN TABLET    
ketorolac tromethamine KETOROLAC TROMETHAMINE CARTRIDGE    
ketorolac tromethamine TORADOL 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    
ziconotide acetate PRIALT VIAL