Antifungals, Oral
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.
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| clotrimazole | CLOTRIMAZOLE | TROCHE | Y | |||
| fluconazole | DIFLUCAN | SUSP RECON | Y | |||
| fluconazole | FLUCONAZOLE | SUSP RECON | Y | |||
| fluconazole | FLUCONAZOLE | TABLET | Y | |||
| nystatin | MYCOSTATIN | ORAL SUSP | Y | |||
| nystatin | NYSTATIN | ORAL SUSP | Y | |||
| nystatin | NYSTATIN | TABLET | Y | |||
| terbinafine HCl | TERBINAFINE HCL | TABLET | Y | |||
| flucytosine | FLUCYTOSINE | CAPSULE | N | Pharmacy PA | ||
| griseofulvin ultramicrosize | GRISEOFULVIN ULTRAMICROSIZE | TABLET | N | Pharmacy PA | ||
| griseofulvin, microsize | GRISEOFULVIN | ORAL SUSP | N | Pharmacy PA | ||
| griseofulvin, microsize | GRISEOFULVIN | TABLET | N | Pharmacy PA | ||
| isavuconazonium sulfate | CRESEMBA | CAPSULE | N | Pharmacy PA | ||
| itraconazole | TOLSURA | CAP SD DSP | N | Pharmacy PA | ||
| itraconazole | ITRACONAZOLE | CAPSULE | N | Pharmacy PA | ||
| itraconazole | SPORANOX | CAPSULE | N | Pharmacy PA | ||
| itraconazole | ITRACONAZOLE | SOLUTION | N | Pharmacy PA | ||
| ketoconazole | KETOCONAZOLE | TABLET | N | Pharmacy PA | ||
| miconazole | ORAVIG | MA BUC TAB | N | Pharmacy PA | ||
| oteseconazole | VIVJOA | CAPSULE | N | Pharmacy PA | ||
| posaconazole | POSACONAZOLE | ORAL SUSP | N | Pharmacy PA | ||
| posaconazole | NOXAFIL | SUSPDR PKT | N | Pharmacy PA | ||
| posaconazole | POSACONAZOLE | TABLET DR | N | Pharmacy PA | ||
| voriconazole | VFEND | SUSP RECON | N | Pharmacy PA | ||
| voriconazole | VORICONAZOLE | SUSP RECON | N | Pharmacy PA | ||
| voriconazole | VFEND | TABLET | N | Pharmacy PA | ||
| voriconazole | VORICONAZOLE | TABLET | N | Pharmacy PA |