Topical Nasal and Otic
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 52817081615 | ACETIC ACID | acetic acid | SOLUTION | 2 % | Y | ||
| 62135080151 | ACETIC ACID | acetic acid | SOLUTION | 2 % | Y | ||
| 64980042415 | ACETIC ACID | acetic acid | SOLUTION | 2 % | Y | ||
| 00026431202 | DOMEBORO | acetic acid/aluminum acetate | DROPS | 2 % | Y | ||
| 00254901043 | A/B OTIC | antipyrine/benzocaine | DROPS | 5.4 %-1.4 % | Y | ||
| 00254933943 | OTICAINE | benzocaine | DROPS | 20 % | Y | ||
| 00904662735 | EAR DROPS | carbamide peroxide | DROPS | 6.5 % | Y | ||
| 00904747835 | EAR WAX REMOVAL | carbamide peroxide | DROPS | 6.5 % | Y | ||
| 11527014351 | EAR WAX REMOVAL | carbamide peroxide | DROPS | 6.5 % | Y | ||
| 11527081074 | EAR WAX REMOVAL | carbamide peroxide | DROPS | 6.5 % | Y | ||
| 46122055605 | EAR WAX REMOVAL | carbamide peroxide | DROPS | 6.5 % | Y | ||
| 46122055705 | EAR WAX REMOVAL | carbamide peroxide | DROPS | 6.5 % | Y | ||
| 70000049001 | EAR WAX REMOVAL | carbamide peroxide | DROPS | 6.5 % | Y | ||
| 70000049002 | EAR WAX REMOVAL | carbamide peroxide | DROPS | 6.5 % | Y | ||
| 70677115301 | EAR WAX REMOVAL | carbamide peroxide | DROPS | 6.5 % | Y | ||
| 70677115401 | EAR WAX REMOVAL | carbamide peroxide | DROPS | 6.5 % | Y | ||
| 64950036204 | COCAINE HCL | cocaine HCl | SOLUTION | 4 % | Y | ||
| 70839036204 | COCAINE HCL | cocaine HCl | SOLUTION | 4 % | Y | ||
| 81665030102 | COCAINE HCL | cocaine HCl | SOLUTION | 4 % | Y | ||
| 64950035904 | GOPRELTO | cocaine HCl | SOLUTION | 4 % | Y | ||
| 81665030002 | NUMBRINO | cocaine HCl | SOLUTION | 4 % | Y | ||
| 68791010320 | DERMOTIC | fluocinolone acetonide oil | DROPS | 0.01 % | Y | ||
| 45802000910 | FLUOCINOLONE ACETONIDE OIL | fluocinolone acetonide oil | DROPS | 0.01 % | Y | ||
| 64980032920 | FLUOCINOLONE ACETONIDE OIL | fluocinolone acetonide oil | DROPS | 0.01 % | Y | ||
| 70752015920 | FLUOCINOLONE ACETONIDE OIL | fluocinolone acetonide oil | DROPS | 0.01 % | Y | ||
| 00642001101 | CORTIC | hydrocort/pramoxine/chloroxyl | DROPS | 10 mg-10 mg-1 mg/mL | Y | ||
| 00713084909 | HYDROCORTISONE-ACETIC ACID | hydrocortisone/acetic acid | DROPS | 1 %-2 % | Y | ||
| 51672300701 | HYDROCORTISONE-ACETIC ACID | hydrocortisone/acetic acid | DROPS | 1 %-2 % | Y | ||
| 71656006410 | HYDROCORTISONE-ACETIC ACID | hydrocortisone/acetic acid | DROPS | 1 %-2 % | Y | ||
| 70000047801 | EAR DROPS FOR SWIMMERS | isopropyl alcohol in glycerin | DROPS | 95 %-5 % | Y | ||
| 00168012691 | SWIM EAR | isopropyl alcohol in glycerin | DROPS | 95 %-5 % | Y | ||
| 10599000301 | SINUVA | mometasone furoate | IMPLANT | 1,350 mcg | Y | ||
| 00254934043 | EAR-GESIC | phenylephrine/antipy/benzocain | DROPS | 0.25 %-5 %-5 % | Y | ||
| 00187526301 | OCEAN COMPLETE | salt irrigation solution no.1 | AER W/ADAP | Y | |||
| 70000027001 | SINUS WASH NETI POT | sod chlor,sod bicarb/neti pot | PACK W/DEV | Y | |||
| 71800002104 | NASAL MOISTURIZING | sodium chloride | SPRAY | 0.65 % | Y | ||
| 71800002105 | NASAL MOISTURIZING | sodium chloride | SPRAY | 0.65 % | Y | ||
| 83035106305 | NASAL MOISTURIZING | sodium chloride | SPRAY | 0.65 % | Y | ||
| 83592004405 | NASAL MOISTURIZING | sodium chloride | SPRAY | 0.65 % | Y | ||
| 45802031758 | SALINE NOSE SPRAY | sodium chloride | SPRAY | 0.65 % | Y | ||
| 70000027002 | SINUS WASH | sodium chloride/sodium bicarb | PACKET | 2,300 mg-700 mg | Y |