Antifungals, 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.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

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Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria Carveout
‐ Bill FFS
New Drug Evaluation & Updates
miconazole nitrate ANTIFUNGAL CREAM CREAM (G) Y   N  
miconazole nitrate ANTIFUNGAL EXTRA THICK CREAM (G) Y   N  
miconazole nitrate DERMAFUNGAL CREAM (G) Y   N  
miconazole nitrate INZO ANTIFUNGAL CREAM (G) Y   N  
miconazole nitrate MICONAZOLE NITRATE CREAM (G) Y   N  
nystatin NYSTATIN CREAM (G) Y   N  
nystatin NYSTATIN OINT. (G) Y   N  
butenafine HCl ATHLETE'S FOOT CREAM (G) N Pharmacy PA N  
ciclopirox CICLOPIROX SHAMPOO N Pharmacy PA N  
ciclopirox CICLODAN SOLUTION N Pharmacy PA N  
ciclopirox olamine CICLODAN CREAM (G) N Pharmacy PA N  
ciclopirox olamine CICLOPIROX SUSPENSION N Pharmacy PA N  
ciclopirox olamine LOPROX SUSPENSION N Pharmacy PA N  
ciclopirox/skin cleanser no.28 CICLODAN COMBO. PKG N Pharmacy PA N  
ciclopirox/skin cleanser no.40 LOPROX COMBO. PKG N Pharmacy PA N  
ciclopirox/urea/camph/men/euc CICLODAN SOLUTION N Pharmacy PA N  
clotrimazole ATHLETE'S FOOT CREAM (G) N Pharmacy PA N  
clotrimazole CLOTRIMAZOLE CREAM (G) N Pharmacy PA N  
clotrimazole ANTIFUNGAL CREAM (G) N Pharmacy PA N  
clotrimazole LOTRIMIN AF CREAM (G) N Pharmacy PA N  
clotrimazole MICOTRIN AC CREAM (G) N Pharmacy PA N  
clotrimazole TRIMAZOLE CREAM (G) N Pharmacy PA N  
clotrimazole/betamethasone dip CLOTRIMAZOLE-BETAMETHASONE LOTION N Pharmacy PA N  
econazole nitrate ECONAZOLE NITRATE FOAM N Pharmacy PA N  
ketoconazole KETOCONAZOLE CREAM (G) N Pharmacy PA N  
ketoconazole KETOCONAZOLE SHAMPOO N Pharmacy PA N  
ketoconazole/skin cleanser 28 KETODAN COMBO. PKG N Pharmacy PA N  
miconazole nitrate ATHLETE'S FOOT SPRAY AERO POWD N Pharmacy PA N  
miconazole nitrate MYCOZYL AP POWDER N Pharmacy PA N  
miconazole nitrate MICONAZORB AF POWDER N Pharmacy PA N  
miconazole nitrate MICONAZOLE NITRATE POWDER N Pharmacy PA N  
miconazole nitrate/zinc ox/pet VUSION OINT. (G) N Pharmacy PA N  
naftifine HCl NAFTIFINE HCL GEL (GRAM) N Pharmacy PA N  
nystatin NYSTOP POWDER N Pharmacy PA N  
nystatin KLAYESTA POWDER N Pharmacy PA N  
nystatin/triamcinolone acet MYTREX CREAM (G) N Pharmacy PA N  
nystatin/triamcinolone acet NYSTATIN-TRIAMCINOLONE CREAM (G) N Pharmacy PA N  
nystatin/triamcinolone acet MYTREX OINT. (G) N Pharmacy PA N  
oxiconazole nitrate OXICONAZOLE NITRATE CREAM (G) N Pharmacy PA N  
sertaconazole nitrate ERTACZO CREAM (G) N Pharmacy PA N  
terbinafine HCl ATHLETE'S FOOT CREAM (G) N Pharmacy PA N  
tolnaftate ATHLETE'S FOOT AERO POWD N Pharmacy PA N  
tolnaftate TOLNAFTATE AERO POWD N Pharmacy PA N  
tolnaftate ANTIFUNGAL CREAM CREAM (G) N Pharmacy PA N  
tolnaftate TOLNAFTATE POWDER N Pharmacy PA N  
tolnaftate TRITOLNACIDE S SOLUTION N Pharmacy PA N  
tolnaftate MYCOZYL AL SOLUTION N Pharmacy PA N  
undecylenic ac/zinc undecylena UNDEX-25 OINT. (G) N Pharmacy PA N  
undecylenic acid TRIPENICOL S SOLUTION N Pharmacy PA N