Sulfonamides

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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
mafenide acetate SULFAMYLON CREAM (G)    
mafenide acetate MAFENIDE ACETATE PACKET    
mafenide acetate SULFAMYLON PACKET    
silver sulfadiazine SILVADENE CREAM (G)    
silver sulfadiazine SILVER SULFADIAZINE CREAM (G)    
silver sulfadiazine SSD CREAM (G)    
sulfacetamide sod/sulfur/urea CLEANSING WASH CLEANSER    
sulfacetamide sod/sulfur/urea SODIUM SULFACETAMIDE-SULFUR CLEANSER    
sulfacetamide sodium/sulfur SUMAXIN CLEANSER    
sulfacetamide sodium/sulfur SUMADAN CLEANSER    
sulfacetamide sodium/sulfur AVAR CLEANSER    
sulfacetamide sodium/sulfur AVAR LS CLEANSER    
sulfacetamide sodium/sulfur BP 10-1 CLEANSER    
sulfacetamide sodium/sulfur SODIUM SULFACETAMIDE-SULFUR CLEANSER    
sulfacetamide sodium/sulfur SSS 10-5 CREAM (G)    
sulfacetamide sodium/sulfur AVAR-E CREAM (G)    
sulfacetamide sodium/sulfur AVAR-E GREEN CREAM (G)    
sulfacetamide sodium/sulfur AVAR-E LS CREAM (G)    
sulfacetamide sodium/sulfur SODIUM SULFACETAMIDE-SULFUR CREAM (G)    
sulfacetamide sodium/sulfur SSS 10-5 FOAM    
sulfacetamide sodium/sulfur AVAR FOAM    
sulfacetamide sodium/sulfur AVAR LS FOAM    
sulfacetamide sodium/sulfur CLARIFOAM EF FOAM    
sulfacetamide sodium/sulfur SODIUM SULFACETAMIDE-SULFUR LOTION    
sulfacetamide sodium/sulfur SUMAXIN MED. PAD    
sulfacetamide sodium/sulfur SULFACETAMIDE SODIUM-SULFUR MED. PAD    
sulfacetamide sodium/sulfur SODIUM SULFACETAMIDE-SULFUR MED. PAD    
sulfacetamide sodium/sulfur AVAR MED. PAD    
sulfacetamide sodium/sulfur AVAR LS MED. PAD    
sulfacetamide sodium/sulfur SUMAXIN TS SUSPENSION    
sulfacetamide sodium/sulfur SODIUM SULFACETAMIDE-SULFUR SUSPENSION    
sulfacetamide/sulfur/cleansr23 SUMADAN KIT    
sulfacetamide/sulfur/cleansr23 SODIUM SULFACETAMIDE-SULFUR KIT    
sulfacetamide/sulfur/cleansr23 SUMAXIN CP KIT    
sulfact sod/sulur/avob/otn/oct SODIUM SULFACETAMIDE-SULFUR CMB CLN CR    
sulfact sod/sulur/avob/otn/oct SUMADAN XLT CMB CLN CR    
sulfadiazine SULFADIAZINE TABLET    
sulfamethoxazole/trimethoprim SULFAMETHOXAZOLE-TRIMETHOPRIM ORAL SUSP    
sulfamethoxazole/trimethoprim SULFATRIM ORAL SUSP    
sulfamethoxazole/trimethoprim BACTRIM DS TABLET    
sulfamethoxazole/trimethoprim BACTRIM TABLET    
sulfamethoxazole/trimethoprim SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET    
sulfamethoxazole/trimethoprim BACTRIM IV VIAL    
sulfamethoxazole/trimethoprim SEPTRA I.V. VIAL    
sulfamethoxazole/trimethoprim SULFAMETHOXAZOLE-TRIMETHOPRIM VIAL    
sulfanilamide AVC CREAM/APPL    
Sulfathiaz/sulfacet/sulfabenz GYNE SULF CREAM/APPL