Hemorroidal Preps
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 |
|---|---|---|---|---|---|---|---|
| 45802074231 | HEMORRHOIDAL | calamine/zinc oxide | SUPP.RECT | 5 %-8.98 % | Y | ||
| 45802074233 | HEMORRHOIDAL | calamine/zinc oxide | SUPP.RECT | 5 %-8.98 % | Y | ||
| 00536121195 | DIBUCAINE | dibucaine | OINT. (G) | 1 % | Y | ||
| 45802005005 | DIBUCAINE | dibucaine | OINT. (G) | 1 % | Y | ||
| 59088081701 | LIDOCAINE-HYDROCORTISONE | hydrocortisone/lidocaine/aloe | GEL W/APPL | 0.55 %-2.8 % | Y | ||
| 42192080401 | ANA-LEX | hydrocortisone/lidocaine/aloe | KIT | 2 %-2 % | Y | ||
| 45802014464 | HYDROCORTISONE-PRAMOXINE | hydrocortisone/pramoxine | CREAM/APPL | 1 %-1 % | Y | ||
| 52817081701 | HYDROCORTISONE-PRAMOXINE | hydrocortisone/pramoxine | CREAM/APPL | 2.5 %-1 % | Y | ||
| 00037682210 | PROCTOFOAM-HC | hydrocortisone/pramoxine | FOAM | 1 %-1 % | Y | ||
| 00536126720 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 00536127803 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 00536135795 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 39328002405 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 39328002415 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 39328002430 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 39328002455 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 61825070105 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 61825070115 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 61825070130 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 71085007519 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 71085007560 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 71800002606 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 83720052301 | LIDOCAINE | lidocaine | CREAM (G) | 4 % | N | Y | |
| 70000065001 | HEMORRHOIDAL RELIEF | lidocaine | CREAM (G) | 5 % | N | Y | |
| 24689012401 | LIDOCAINE | lidocaine | CREAM (G) | 5 % | N | Y | |
| 39328002515 | LIDOCAINE | lidocaine | CREAM (G) | 5 % | N | Y | |
| 39328002530 | LIDOCAINE | lidocaine | CREAM (G) | 5 % | N | Y | |
| 75834014130 | LIDOCAINE | lidocaine | CREAM (G) | 5 % | N | Y | |
| 82429020301 | NUMBCREAM | lidocaine | CREAM (G) | 5 % | N | Y | |
| 69315030130 | RECTASMOOTHE | lidocaine | CREAM (G) | 5 % | N | Y | |
| 59088081914 | LIDOCAINE-HYDROCORTISONE | lidocaine/hydrocortisone ac | CREAM/APPL | 3 %-0.5 % | Y | ||
| 13925016407 | LIDOCAINE-HYDROCORTISONE | lidocaine/hydrocortisone ac | GEL W/APPL | 3 %-2.5 % (7 gram) | Y | ||
| 59088081624 | LIDOCAINE-HYDROCORTISONE | lidocaine/hydrocortisone ac | KIT | 2 %-2 % (7 gram) | Y | ||
| 13925016520 | LIDOCAINE-HYDROCORTISONE | lidocaine/hydrocortisone ac | KIT | 3 %-0.5 % | Y | ||
| 59088081920 | LIDOCAINE-HYDROCORTISONE | lidocaine/hydrocortisone ac | KIT | 3 %-0.5 % | Y | ||
| 13925016420 | LIDOCAINE-HYDROCORTISONE | lidocaine/hydrocortisone ac | KIT | 3 %-2.5 % (7 gram) | Y | ||
| 49348042832 | HEMORRHOIDAL CREAM | pe/shark liver oil/glyc/wh.pet | CREAM (G) | Y | |||
| 00113018816 | HEMORRHOIDAL OINTMENT | phenyleph/mineral oil/petrolat | OINT/APPL | 0.25 %-14 %-74.9 % | Y | ||
| 00536128806 | HEMORRHOIDAL OINTMENT | phenyleph/mineral oil/petrolat | OINT/APPL | 0.25 %-14 %-74.9 % | Y | ||
| 45802018816 | HEMORRHOIDAL OINTMENT | phenyleph/mineral oil/petrolat | OINT/APPL | 0.25 %-14 %-74.9 % | Y | ||
| 46122067746 | HEMORRHOIDAL OINTMENT | phenyleph/mineral oil/petrolat | OINT/APPL | 0.25 %-14 %-74.9 % | Y | ||
| 70000004601 | HEMORRHOIDAL OINTMENT | phenyleph/mineral oil/petrolat | OINT/APPL | 0.25 %-14 %-74.9 % | Y | ||
| 70677110801 | HEMORRHOIDAL OINTMENT | phenyleph/mineral oil/petrolat | OINT/APPL | 0.25 %-14 %-74.9 % | Y | ||
| 00113094424 | HEMORRHOIDAL CREAM | phenyleph/pramoxin/glycr/w.pet | CREAM (G) | 0.25 %-1 % | Y | ||
| 70000042501 | HEMORRHOIDAL CREAM | phenyleph/pramoxin/glycr/w.pet | CREAM (G) | 0.25 %-1 % | Y | ||
| 46122077637 | HEMORRHOIDAL PAIN RELIEF | phenyleph/pramoxin/glycr/w.pet | CREAM (G) | 0.25 %-1 % | Y | ||
| 45802074030 | HEMORRHOIDAL | phenyleph/shark oil/cocoa butr | SUPP.RECT | 0.25 %-3 % | Y | ||
| 45802074214 | HEMORRHOIDAL | phenyleph/shark oil/cocoa butr | SUPP.RECT | 0.25 %-3 % | Y | ||
| 45802070730 | PREP-HEM | phenyleph/shark oil/cocoa butr | SUPP.RECT | 0.25 %-3 % | Y | ||
| 45802070731 | PREP-HEM | phenyleph/shark oil/cocoa butr | SUPP.RECT | 0.25 %-3 % | Y | ||
| 00113027953 | HEMORRHOIDAL SUPPOSITORIES | phenylephrine HCl/cocoa butter | SUPP.RECT | 0.25 %-88.44 % | Y | ||
| 00536118612 | HEMORRHOIDAL SUPPOSITORIES | phenylephrine HCl/cocoa butter | SUPP.RECT | 0.25 %-88.44 % | Y | ||
| 46122077765 | HEMORRHOIDAL SUPPOSITORIES | phenylephrine HCl/cocoa butter | SUPP.RECT | 0.25 %-88.44 % | Y | ||
| 70000022301 | HEMORRHOIDAL SUPPOSITORIES | phenylephrine HCl/cocoa butter | SUPP.RECT | 0.25 %-88.44 % | Y | ||
| 70677129201 | HEMORRHOIDAL SUPPOSITORIES | phenylephrine HCl/cocoa butter | SUPP.RECT | 0.25 %-88.44 % | Y | ||
| 00904697712 | HEMORRHOIDAL SUPPOSITORY | phenylephrine HCl/hard fat | SUPP.RECT | 0.25 %-88.7 % | Y | ||
| 49348051032 | HEMORRHOIDAL SOOTHING | phenylephrine HCl/witch hazel | GEL (GRAM) | 0.25 %-50 % | Y | ||
| 51862018015 | PRAMOXINE HCL | pramoxine HCl | FOAM | 1 % | Y | ||
| 00037682315 | PROCTOFOAM | pramoxine HCl | FOAM | 1 % | Y | ||
| 11527005641 | HEMORRHOID | pramoxine HCl/zinc oxide | OINT. (G) | 1 %-12.5 % | Y | ||
| 45802075331 | HEMORRHOIDAL | soybean oil/starch | SUPP.RECT | 51 % | Y | ||
| 70000036401 | HEMORRHOIDAL PADS | witch hazel | MED. PAD | 50 % | Y | ||
| 00904682960 | MEDI-PADS | witch hazel | MED. PAD | 50 % | Y | ||
| 83324031101 | MEDICATED COOLING PADS | witch hazel | MED. PAD | 50 % | Y |