Acne

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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 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
clindamycin phos/skin clnsr 19 CLINDACIN PAC KIT N PA Document  
clindamycin phos/skin clnsr 19 CLINDACIN ETZ KIT N PA Document  
clindamycin phosphate EVOCLIN FOAM N PA Document  
clindamycin phosphate CLINDAMYCIN PHOSPHATE FOAM N PA Document  
clindamycin phosphate CLINDAMYCIN PHOSPHATE GEL (GRAM) N PA Document  
clindamycin phosphate CLEOCIN T GEL (GRAM) N PA Document  
clindamycin phosphate CLINDAMYCIN PHOSPHATE LOTION N PA Document  
clindamycin phosphate CLEOCIN T LOTION N PA Document  
clindamycin phosphate CLEOCIN T MED. SWAB N PA Document  
clindamycin phosphate CLINDAMYCIN PHOSPHATE MED. SWAB N PA Document  
clindamycin phosphate CLINDACIN ETZ MED. SWAB N PA Document  
clindamycin phosphate CLINDACIN P MED. SWAB N PA Document  
clindamycin phosphate CLINDAMYCIN PHOSPHATE SOLUTION N PA Document  
erythromycin base DEL-MYCIN SOLUTION N PA Document  
erythromycin base in ethanol ERYTHROMYCIN GEL (GRAM) N PA Document  
erythromycin base in ethanol ERYGEL GEL (GRAM) N PA Document  
erythromycin base in ethanol ERYTHROMYCIN MED. SWAB N PA Document  
erythromycin base in ethanol ERY MED. SWAB N PA Document  
erythromycin base in ethanol ERYTHROMYCIN SOLUTION N PA Document  
erythromycin/benzoyl peroxide BENZAMYCINPAK GEL (EA) N PA Document  
erythromycin/benzoyl peroxide ERYTHROMYCIN-BENZOYL PEROXIDE GEL (GRAM) N PA Document  
erythromycin/benzoyl peroxide BENZAMYCIN GEL (GRAM) N PA Document  
adapalene DIFFERIN CREAM (G) PA Document  
adapalene ADAPALENE CREAM (G) PA Document  
adapalene ADAPALENE GEL (GRAM) PA Document  
adapalene DIFFERIN GEL (GRAM) PA Document  
adapalene ADAPALENE GEL W/PUMP PA Document  
adapalene DIFFERIN GEL W/PUMP PA Document  
adapalene DIFFERIN LOTION PA Document  
adapalene PLIXDA MED. SWAB PA Document  
adapalene ADAPALENE SOLUTION PA Document  
adapalene/benzoyl peroxide ADAPALENE-BENZOYL PEROXIDE GEL W/PUMP PA Document  
adapalene/benzoyl peroxide EPIDUO GEL W/PUMP PA Document  
adapalene/benzoyl peroxide EPIDUO FORTE GEL W/PUMP PA Document  
azelaic acid AZELEX CREAM (G) PA Document  
azelaic acid FINEVIN CREAM (G) PA Document  
azelaic acid FINACEA FOAM PA Document Mar 31, 2016
azelaic acid AZELAIC ACID GEL (GRAM) PA Document  
azelaic acid FINACEA GEL (GRAM) PA Document  
benzoyl peroxide PANOXYL-4 CLEANSER PA Document  
benzoyl peroxide BENZOYL PEROXIDE CLEANSER PA Document  
benzoyl peroxide PACNEX CLEANSER PA Document  
benzoyl peroxide BENZOYL PEROXIDE FOAM PA Document  
benzoyl peroxide PANOXYL AQ 5 GEL (GRAM) PA Document  
benzoyl peroxide PANOXYL AQ 2.5 GEL (GRAM) PA Document  
benzoyl peroxide ACNE MEDICATION GEL (GRAM) PA Document  
benzoyl peroxide BENZAC W 10 GEL (GRAM) PA Document  
benzoyl peroxide BENZAC W 2.5 GEL (GRAM) PA Document  
benzoyl peroxide BENZAC W 5 GEL (GRAM) PA Document  
benzoyl peroxide BENZOYL PEROXIDE GEL (GRAM) PA Document  
benzoyl peroxide BPO GEL (GRAM) PA Document  
benzoyl peroxide DEL-AQUA-5 GEL (GRAM) PA Document  
benzoyl peroxide BPO TOWELETTE PA Document  
clindamycin phos/benzoyl perox BENZACLIN GEL (GRAM) PA Document  
clindamycin phos/benzoyl perox CLINDAMYCIN PHOS-BENZOYL PEROX GEL (GRAM) PA Document  
clindamycin phos/benzoyl perox CLINDAMYCIN-BENZOYL PEROXIDE GEL (GRAM) PA Document  
clindamycin phos/benzoyl perox ONEXTON GEL (GRAM) PA Document  
clindamycin phos/benzoyl perox NEUAC GEL (GRAM) PA Document  
clindamycin phos/benzoyl perox DUAC GEL (GRAM) PA Document  
clindamycin phos/benzoyl perox ACANYA GEL W/PUMP PA Document  
clindamycin phos/benzoyl perox BENZACLIN GEL W/PUMP PA Document  
clindamycin phos/benzoyl perox CLINDAMYCIN PHOS-BENZOYL PEROX GEL W/PUMP PA Document  
clindamycin phos/benzoyl perox CLINDAMYCIN-BENZOYL PEROXIDE GEL W/PUMP PA Document  
clindamycin phos/benzoyl perox ONEXTON GEL W/PUMP PA Document  
clindamycin/benzoyl/emol cmb94 NEUAC CMB CR GEL PA Document  
clindamycin/tretinoin CLINDAMYCIN PHOS-TRETINOIN GEL (GRAM) PA Document  
clindamycin/tretinoin ZIANA GEL (GRAM) PA Document  
dapsone ACZONE GEL (GRAM) PA Document  
dapsone DAPSONE GEL (GRAM) PA Document  
dapsone ACZONE GEL W/PUMP PA Document  
isotretinoin ABSORICA CAPSULE PA Document  
isotretinoin ZENATANE CAPSULE PA Document  
isotretinoin MYORISAN CAPSULE PA Document  
isotretinoin ISOTRETINOIN CAPSULE PA Document  
isotretinoin CLARAVIS CAPSULE PA Document  
isotretinoin AMNESTEEM CAPSULE PA Document  
sulfacetamide sodium SULFACETAMIDE SODIUM SUSPENSION PA Document  
sulfacetamide sodium KLARON SUSPENSION PA Document  
tazarotene FABIOR FOAM PA Document  
tretinoin TRETIN-X CREAM (G) PA Document  
tretinoin RETIN-A CREAM (G) PA Document  
tretinoin TRETINOIN CREAM (G) PA Document  
tretinoin AVITA CREAM (G) PA Document  
tretinoin TRETINOIN GEL (GRAM) PA Document  
tretinoin RETIN-A GEL (GRAM) PA Document  
tretinoin ATRALIN GEL (GRAM) PA Document  
tretinoin AVITA GEL (GRAM) PA Document  
tretinoin microspheres TRETINOIN MICROSPHERE GEL (GRAM) PA Document  
tretinoin microspheres RETIN-A MICRO GEL (GRAM) PA Document  
tretinoin microspheres TRETINOIN MICROSPHERE GEL W/PUMP PA Document  
tretinoin microspheres RETIN-A MICRO PUMP GEL W/PUMP PA Document  
tretinoin/emol 9/skin cleansr1 TRETIN-X COMBO. PKG PA Document