Antipsoriatics, Topical

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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
calcipotriene CALCIPOTRIENE CREAM (G) Y PA Document  
calcipotriene DOVONEX CREAM (G) Y PA Document  
calcipotriene CALCIPOTRIENE SOLUTION Y PA Document  
calcipotriene/betamethasone CALCIPOTRIENE-BETAMETHASONE DP OINT. (G) Y PA Document  
calcipotriene/betamethasone TACLONEX OINT. (G) Y PA Document  
tazarotene TAZAROTENE CREAM (G) Y PA Document  
tazarotene TAZORAC CREAM (G) Y PA Document  
tazarotene TAZORAC GEL (GRAM) Y PA Document  
anthralin ANTHRALIN CREAM (G) N PA Document  
calcipotriene SORILUX FOAM N PA Document  
calcipotriene CALCITRENE OINT. (G) N PA Document  
calcipotriene CALCIPOTRIENE OINT. (G) N PA Document  
calcipotriene/betamethasone ENSTILAR FOAM N PA Document  
calcipotriene/betamethasone TACLONEX SUSPENSION N PA Document  
calcitriol CALCITRIOL OINT. (G) N PA Document  
calcitriol VECTICAL OINT. (G) N PA Document  
coal tar SCYTERA FOAM N PA Document  
coal tar PSORIATAR FOAM N PA Document  
coal tar OXIPOR VHC LOTION N PA Document  
coal tar TEGRIN PSORIASIS LOTION N PA Document  
coal tar DHS TAR GEL SHAMPOO N PA Document  
coal tar IONIL T SHAMPOO N PA Document  
coal tar POLYTAR SHAMPOO N PA Document  
coal tar THERA-GEL SHAMPOO N PA Document  
coal tar DHS TAR SHAMPOO N PA Document  
coal tar ANTI-DANDRUFF SHAMPOO N PA Document  
tazarotene AVAGE CREAM (G) N PA Document