Oral Analgesics, Other
PDL Reference Documents
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| acetaminophen/d-brompheniramin | DOLOGESIC | LIQUID | N | |||
| acetaminophen/d-brompheniramin | DOLOGESIC-DF | TABLET | N | |||
| acetaminophen/d-brompheniramin | DOLOGESIC | TABLET | N | |||
| acetaminophen/diphenhydramine | PM PAIN RELIEF | TABLET | N | |||
| acetaminophen/diphenhydramine | PAIN RELIEVER PM | TABLET | N | |||
| acetaminophen/diphenhydramine | PAIN RELIEF PM | TABLET | N | |||
| acetaminophen/diphenhydramine | EXT STR PAIN RELIEF/SLEEP | TABLET | N | |||
| acetaminophen/diphenhydramine | ACETAMINOPHEN PM | TABLET | N | |||
| aspirin/acetaminophn/diphenhyd | PAIN RELIEF PM | TABLET | N | |||
| butalb/acetaminophen/caffeine | BUTALBITAL-ACETAMINOPHEN-CAFFE | CAPSULE | N | Pharmacy PA | ||
| butalb/acetaminophen/caffeine | FIORICET | CAPSULE | N | Pharmacy PA | ||
| butalb/acetaminophen/caffeine | BUTALBITAL-ACETAMINOPHEN-CAFFE | SOLUTION | N | Pharmacy PA | ||
| butalb/acetaminophen/caffeine | BUTALBITAL-ACETAMINOPHEN-CAFFE | TABLET | N | Pharmacy PA | ||
| butalb/acetaminophen/caffeine | QUALA-CET | TABLET | N | Pharmacy PA | ||
| butalbital/acetaminophen | BUTALBITAL-ACETAMINOPHEN | CAPSULE | N | Pharmacy PA | ||
| butalbital/acetaminophen | BUTALBITAL-ACETAMINOPHEN | TABLET | N | Pharmacy PA | ||
| butalbital/acetaminophen | REPAN-CF | TABLET | N | Pharmacy PA | ||
| butalbital/aspirin/caffeine | BUTALBITAL-ASPIRIN-CAFFEINE | CAPSULE | N | Pharmacy PA | ||
| acetaminophen | MAPAP | CAPSULE | ||||
| acetaminophen | INFANT DROPS | DROPS | ||||
| acetaminophen | INFANT'S NON-ASPIRIN | DROPS | ||||
| acetaminophen | INFANT'S NON-ASPIRIN | DROPS SUSP | ||||
| acetaminophen | ACETAMINOPHEN | ELIXIR | ||||
| acetaminophen | ACETAMINOPHEN | LIQUID | ||||
| acetaminophen | ED-APAP | LIQUID | ||||
| acetaminophen | CHILDREN'S PAIN AND FEVER | LIQUID | ||||
| acetaminophen | CHILDREN'S ACETAMINOPHEN | LIQUID | ||||
| acetaminophen | REDUTEMP | LIQUID | ||||
| acetaminophen | M-PAP | LIQUID | ||||
| acetaminophen | MAPAP | LIQUID | ||||
| acetaminophen | ACETAMINOPHEN | ORAL SUSP | ||||
| acetaminophen | CHILDREN'S PAIN-FEVER | ORAL SUSP | ||||
| acetaminophen | INFANTS' ACETAMINOPHEN | ORAL SUSP | ||||
| acetaminophen | CHILDREN'S PAIN RELIEF | ORAL SUSP | ||||
| acetaminophen | CHILDREN'S ACETAMINOPHEN | ORAL SUSP | ||||
| acetaminophen | MAPAP CHILDREN'S | ORAL SUSP | ||||
| acetaminophen | INFANTS' PAIN-FEVER | ORAL SUSP | ||||
| acetaminophen | ACETAMINOPHEN | SOLUTION | ||||
| acetaminophen | ACETAMINOPHEN | SYRINGE | ||||
| acetaminophen | CHILDREN'S PAIN RELIEF | TAB CHEW | ||||
| acetaminophen | CHILDREN'S MAPAP | TAB CHEW | ||||
| acetaminophen | CHILDREN'S ACETAMINOPHEN | TAB CHEW | ||||
| acetaminophen | CHILDREN'S PAIN-FEVER RELIEF | 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 | 8 HOUR ACETAMINOPHEN | TABLET ER | ||||
| acetaminophen | 8 HOUR PAIN RELIEF | TABLET ER | ||||
| acetaminophen | 8HR ARTHRITIS PAIN | TABLET ER | ||||
| acetaminophen | 8HR ARTHRITIS PAIN RELIEF | TABLET ER | ||||
| 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 RELIEF | TABLET ER | ||||
| 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 | ||||
| acetaminophen/pyrilam/pamabrom | MENSTRUAL PAIN RELIEF | TABLET | ||||
| acetaminophen/pyrilamine/caff | MENSTRUAL COMPLETE | TABLET | ||||
| ASA/acetaminophen/caffeine/cal | SUPAC | TABLET | ||||
| aspirin/acetaminophen/caffeine | PAIN RELIEVER PLUS | TABLET | ||||
| aspirin/acetaminophen/caffeine | MIGRAINE RELIEF | TABLET | ||||
| aspirin/acetaminophen/caffeine | EXTRA PAIN RELIEF | TABLET | ||||
| aspirin/acetaminophen/caffeine | HEADACHE RELIEF | TABLET | ||||
| aspirin/acetaminophen/caffeine | ASPIRIN-ACETAMINPHEN-CAFFEINE | TABLET | ||||
| aspirin/acetaminophen/caffeine | MIGRAINE FORMULA | 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 | ||||
| ibuprofen/diphenhydramine cit | IBUPROFEN PM | TABLET | ||||
| sal-amide/acetaminophen/p-tlox | CETAZONE-T | TABLET | ||||
| suzetrigine | JOURNAVX | TABLET | Pharmacy PA | Jun 05, 2025 |