Hemorroidal Preps

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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
HYDROCORTISONE/LIDOCAINE/ALOE LIDOCAINE-HYDROCORTISONE GEL W/APPL    
HYDROCORTISONE/LIDOCAINE/ALOE LIDOCAINE-HYDROCORTISONE KIT    
HYDROCORTISONE/PRAMOXINE PROCORT CREAM/APPL    
HYDROCORTISONE/PRAMOXINE PRAMCORT CREAM/APPL    
HYDROCORTISONE/PRAMOXINE HYDROCORTISONE-PRAMOXINE CREAM/APPL    
HYDROCORTISONE/PRAMOXINE ANALPRAM HC CREAM/APPL    
HYDROCORTISONE/PRAMOXINE PROCTOFOAM-HC FOAM    
LIDOCAINE/HYDROCORTISONE AC LIDOCAINE-HYDROCORTISONE CREAM/APPL    
LIDOCAINE/HYDROCORTISONE AC LIDOCAINE-HYDROCORTISONE KIT    
PHENYLEPH/MINERAL OIL/PETROLAT MAJOR-PREP HEMORRHOIDAL OINT/APPL    
PHENYLEPH/MINERAL OIL/PETROLAT HEMORRHOIDAL OINTMENT OINT/APPL    
PHENYLEPH/PRAMOXIN/GLYCR/W.PET HEMORRHOIDAL CREAM CREAM (G)    
PHENYLEPH/SHARK LIV.OIL/MO/PET HEMORRHOIDAL OINTMENT OINT. (G)    
PHENYLEPHRINE HCL ANU-MED SUPP.RECT    
PHENYLEPHRINE HCL HEMORRHOIDAL SUPP.RECT    
PHENYLEPHRINE HCL HEMORRHOIDAL SUPPOSITORY SUPP.RECT    
PHENYLEPHRINE HCL/COCOA BUTTER HEMORRHOIDAL SUPPOSITORIES SUPP.RECT    
PHENYLEPHRINE HCL/WITCH HAZEL HEMORRHOIDAL COOLING GEL GEL (GRAM)    
PRAMOXINE HCL PROCTOFOAM FOAM