Antifungals, Topical
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 | New Drug Evaluation |
---|---|---|---|---|---|
miconazole nitrate | MICONAZOLE NITRATE | CREAM (G) | Y | ||
miconazole nitrate | ANTIFUNGAL CREAM | CREAM (G) | Y | ||
miconazole nitrate | BAZA ANTIFUNGAL | CREAM (G) | Y | ||
miconazole nitrate | MICONAZOLE NITRATE | CREAM (G) | Y | ||
miconazole nitrate | MICATIN | CREAM (G) | Y | ||
miconazole nitrate | DERMAFUNGAL | CREAM (G) | Y | ||
miconazole nitrate | ANTIFUNGAL EXTRA THICK | CREAM (G) | Y | ||
miconazole nitrate | ANTIFUNGAL CREAM | CREAM (G) | Y | ||
miconazole nitrate | INZO ANTIFUNGAL | CREAM (G) | Y | ||
nystatin | NYSTATIN | CREAM (G) | Y | ||
nystatin | NYSTATIN | OINT. (G) | Y | ||
acetic ac/resorcino/salicyl ac | ANTIFUNGAL NAIL | TINCTURE | N | PA Document | |
butenafine HCl | BUTENAFINE HCL | CREAM (G) | N | PA Document | |
ciclopirox | CICLOPIROX | GEL (GRAM) | N | PA Document | |
ciclopirox | CICLOPIROX | SHAMPOO | N | PA Document | |
ciclopirox | CICLOPIROX | SOLUTION | N | PA Document | |
ciclopirox | CICLODAN | SOLUTION | N | PA Document | |
ciclopirox olamine | LOPROX | CREAM (G) | N | PA Document | |
ciclopirox olamine | CICLOPIROX | CREAM (G) | N | PA Document | |
ciclopirox olamine | CICLODAN | CREAM (G) | N | PA Document | |
ciclopirox olamine | CICLOPIROX | SUSPENSION | N | PA Document | |
ciclopirox olamine | LOPROX | SUSPENSION | N | PA Document | |
ciclopirox/skin cleanser no.28 | CICLODAN | COMBO. PKG | N | PA Document | |
ciclopirox/skin cleanser no.40 | LOPROX | COMBO. PKG | N | PA Document | |
ciclopirox/skin cleanser no.40 | LOPROX | KIT SS-CLN | N | PA Document | |
ciclopirox/urea/camph/men/euc | CICLOPIROX | SOLUTION | N | PA Document | |
ciclopirox/urea/camph/men/euc | CICLODAN | SOLUTION | N | PA Document | |
clotrimazole | FUNGOID | CREAM (G) | N | PA Document | |
clotrimazole | CLOTRIMAZOLE | CREAM (G) | N | PA Document | |
clotrimazole | ANTIFUNGAL | CREAM (G) | N | PA Document | |
clotrimazole | LOTRIMIN AF | CREAM (G) | N | PA Document | |
clotrimazole | ATHLETE'S FOOT | CREAM (G) | N | PA Document | |
clotrimazole | MICOTRIN AC | CREAM (G) | N | PA Document | |
clotrimazole | MYCOZYL AC | CREAM (G) | N | PA Document | |
clotrimazole | TRIMAZOLE | CREAM (G) | N | PA Document | |
clotrimazole | VOTRIZA-AL | LOTION | N | PA Document | |
clotrimazole | ALEVAZOL | OINT. (G) | N | PA Document | |
clotrimazole | FUNGOID | SOLUTION | N | PA Document | |
clotrimazole | CLOTRIMAZOLE | SOLUTION | N | PA Document | |
clotrimazole/betamethasone dip | CLOTRIMAZOLE-BETAMETHASONE | CREAM (G) | N | PA Document | |
clotrimazole/betamethasone dip | CLOTRIMAZOLE-BETAMETHASONE | LOTION | N | PA Document | |
econazole nitrate | ECONAZOLE NITRATE | CREAM (G) | N | PA Document | |
efinaconazole | JUBLIA | SOL W/APPL | N | PA Document | |
ketoconazole | KETOCONAZOLE | CREAM (G) | N | PA Document | |
ketoconazole | KETODAN | FOAM | N | PA Document | |
ketoconazole | KETOCONAZOLE | FOAM | N | PA Document | |
ketoconazole | KETOCONAZOLE | SHAMPOO | N | PA Document | |
ketoconazole/skin cleanser 28 | KETODAN | COMBO. PKG | N | PA Document | |
luliconazole | LUZU | CREAM (G) | N | PA Document | |
luliconazole | LULICONAZOLE | CREAM (G) | N | PA Document | |
miconazole nitrate | ATHLETE'S FOOT SPRAY | AERO POWD | N | PA Document | |
miconazole nitrate | THERA ANTIFUNGAL | CREAM(ML) | N | PA Document | |
miconazole nitrate | MICONI-AL | LIQUID | N | PA Document | |
miconazole nitrate | ALOE VESTA | OINT.(ML) | N | PA Document | |
miconazole nitrate | THERA ANTIFUNGAL | POWDER | N | PA Document | |
miconazole nitrate | MYCOZYL AP | POWDER | N | PA Document | |
miconazole nitrate | MICOTRIN AP | POWDER | N | PA Document | |
miconazole nitrate | MICONAZORB AF | POWDER | N | PA Document | |
miconazole nitrate | MICONAZOLE NITRATE | POWDER | N | PA Document | |
miconazole nitrate | ANTIFUNGAL POWDER | POWDER | N | PA Document | |
miconazole nitrate | MICONAZOLE NITRATE | SOL W/APPL | N | PA Document | |
miconazole nitrate | FUNGOID TINCTURE | TINCTURE | N | PA Document | |
miconazole nitrate/zinc ox/pet | VUSION | OINT. (G) | N | PA Document | |
miconazole nitrate/zinc ox/pet | MICONAZOLE-ZINC OXIDE-PETROLTM | OINT. (G) | N | PA Document | |
naftifine HCl | NAFTIFINE HCL | CREAM (G) | N | PA Document | |
naftifine HCl | NAFTIN | GEL (GRAM) | N | PA Document | |
naftifine HCl | NAFTIFINE HCL | GEL (GRAM) | N | PA Document | |
nystatin | NYSTATIN | POWDER | N | PA Document | |
nystatin | NYSTOP | POWDER | N | PA Document | |
nystatin | NYAMYC | POWDER | N | PA Document | |
nystatin | KLAYESTA | POWDER | N | PA Document | |
nystatin/triamcinolone acet | N.T.A. | CREAM (G) | N | PA Document | |
nystatin/triamcinolone acet | MYCONEL | CREAM (G) | N | PA Document | |
nystatin/triamcinolone acet | MYTREX | CREAM (G) | N | PA Document | |
nystatin/triamcinolone acet | NYSTATIN-TRIAMCINOLONE | CREAM (G) | N | PA Document | |
nystatin/triamcinolone acet | MYTREX | OINT. (G) | N | PA Document | |
nystatin/triamcinolone acet | N.T.A. | OINT. (G) | N | PA Document | |
nystatin/triamcinolone acet | NYSTATIN-TRIAMCINOLONE | OINT. (G) | N | PA Document | |
oxiconazole nitrate | OXICONAZOLE NITRATE | CREAM (G) | N | PA Document | |
oxiconazole nitrate | OXISTAT | LOTION | N | PA Document | |
sertaconazole nitrate | ERTACZO | CREAM (G) | N | PA Document | |
tavaborole | TAVABOROLE | SOL W/APPL | N | PA Document | |
terbinafine HCl | ATHLETE'S FOOT AF | CREAM (G) | N | PA Document | |
terbinafine HCl | TERBINAFINE | CREAM (G) | N | PA Document | |
terbinafine HCl | ATHLETE'S FOOT | CREAM (G) | N | PA Document | |
tolnaftate | ATHLETE'S FOOT | AERO POWD | N | PA Document | |
tolnaftate | TOLNAFTATE | AERO POWD | N | PA Document | |
tolnaftate | TOLNAFTATE | CREAM (G) | N | PA Document | |
tolnaftate | ANTIFUNGAL CREAM | CREAM (G) | N | PA Document | |
tolnaftate | TRITOLNACIDE C | CREAM(ML) | N | PA Document | |
tolnaftate | TOLNAFTATE | POWDER | N | PA Document | |
tolnaftate | ANTIFUNGAL | SOLUTION | N | PA Document | |
tolnaftate | MYCOZYL AL | SOLUTION | N | PA Document | |
tolnaftate | TRITOLNACIDE S | SOLUTION | N | PA Document | |
tolnaftate | TOLNAFTATE | SOLUTION | N | PA Document | |
tolnaftate | TOLNAFI-AL | SOLUTION | N | PA Document | |
tolnaftate | MICOTRIN AL | SOLUTION | N | PA Document | |
tolnaftate | MICOMITIN | SOLUTION | N | PA Document | |
undecylenic ac/zinc undecylena | ANTIFUNGAL CREAM | CREAM (G) | N | PA Document | |
undecylenic ac/zinc undecylena | UNDEX-25 | OINT. (G) | N | PA Document | |
undecylenic acid | TRIPENICOL C | CREAM(ML) | N | PA Document | |
undecylenic acid | TRIPENICOL S | SOLUTION | N | PA Document | |
econazole/triamcinolone | TRIAMAZOLE | CMB ONT CR | |||
gentian violet/brgreen/proflav | TRIPLE DYE | MED. SWAB | |||
gentian violet/brilliant green | TRIPLE DYE | LIQUID |