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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| ciclopirox | CICLOPIROX | GEL (GRAM) | Y | |||
| ciclopirox | CICLOPIROX | SOLUTION | Y | |||
| ciclopirox | CICLODAN | SOLUTION | Y | |||
| ciclopirox olamine | LOPROX | CREAM (G) | Y | |||
| ciclopirox olamine | CICLOPIROX | CREAM (G) | Y | |||
| ciclopirox olamine | CICLODAN | CREAM (G) | Y | |||
| clotrimazole | ANTIFUNGAL | CREAM (G) | Y | |||
| clotrimazole | CLOTRIMAZOLE | CREAM (G) | Y | |||
| clotrimazole | ATHLETE'S FOOT | CREAM (G) | Y | |||
| clotrimazole | MICOTRIN AC | CREAM (G) | Y | |||
| clotrimazole | LOTRIMIN AF | CREAM (G) | Y | |||
| clotrimazole | MYCOZYL AC | CREAM (G) | Y | |||
| clotrimazole | TRIMAZOLE | CREAM (G) | Y | |||
| clotrimazole | CLOTRIMAZOLE ANTIFUNGAL | CREAM (G) | Y | |||
| clotrimazole | CLOTRIMAZOLE AF | CREAM (G) | Y | |||
| clotrimazole | CLOTRIMAZOLE | CREAM (G) | Y | |||
| clotrimazole | ATHLETIC FOOT CREAM | CREAM (G) | Y | |||
| clotrimazole | ATHLETE'S FOOT | CREAM (G) | Y | |||
| clotrimazole | ANTIFUNGAL | CREAM (G) | Y | |||
| clotrimazole | DESENEX | CREAM (G) | Y | |||
| clotrimazole | ANTIFUNGAL RINGWORM | CREAM (G) | Y | |||
| clotrimazole | ITCH RELIEF | CREAM (G) | Y | |||
| clotrimazole | RINGWORM | CREAM (G) | Y | |||
| clotrimazole | MYCELEX | CREAM (G) | Y | |||
| clotrimazole | LOTRIMIN AF | CREAM (G) | Y | |||
| clotrimazole | JOCK ITCH RELIEF | CREAM (G) | Y | |||
| clotrimazole | JOCK ITCH | CREAM (G) | Y | |||
| clotrimazole/betamethasone dip | CLOTRIMAZOLE-BETAMETHASONE | CREAM (G) | Y | |||
| ketoconazole | KETOCONAZOLE | CREAM (G) | Y | |||
| ketoconazole | KETOCONAZOLE | SHAMPOO | Y | |||
| ketoconazole | NIZORAL A-D | SHAMPOO | Y | |||
| miconazole nitrate | MICONAZOLE NITRATE | CREAM (G) | Y | |||
| miconazole nitrate | ANTIFUNGAL CREAM | CREAM (G) | Y | |||
| miconazole nitrate | MICATIN | CREAM (G) | Y | |||
| miconazole nitrate | MICONAZOLE NITRATE | CREAM (G) | Y | |||
| miconazole nitrate | INZO ANTIFUNGAL | CREAM (G) | Y | |||
| miconazole nitrate | DESENEX | 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 | BAZA ANTIFUNGAL | CREAM (G) | Y | |||
| miconazole nitrate | THERA ANTIFUNGAL | POWDER | Y | |||
| miconazole nitrate | MYCOZYL AP | POWDER | Y | |||
| miconazole nitrate | MICOTRIN AP | POWDER | Y | |||
| miconazole nitrate | MICONAZORB AF | POWDER | Y | |||
| miconazole nitrate | MICONAZOLE NITRATE | POWDER | Y | |||
| miconazole nitrate | ANTIFUNGAL POWDER | POWDER | Y | |||
| miconazole nitrate | ATHLETES FOOT | POWDER | Y | |||
| miconazole nitrate | ZEASORB AF | POWDER | Y | |||
| miconazole nitrate | REMEDY PHYTOPLEX ANTIFUNGAL | POWDER | Y | |||
| miconazole nitrate | REMEDY ANTIFUNGAL | POWDER | Y | |||
| miconazole nitrate | MICRO-GUARD | POWDER | Y | |||
| miconazole nitrate | MICONAZOLE NITRATE | POWDER | Y | |||
| miconazole nitrate | DESENEX | POWDER | Y | |||
| miconazole nitrate | ATHLETE'S FOOT | POWDER | Y | |||
| miconazole nitrate | ANTI-FUNGAL POWDER | POWDER | Y | |||
| miconazole nitrate | ANTIFUNGAL POWDER | POWDER | Y | |||
| miconazole nitrate | MICONAZOLE NITRATE | SOL W/APPL | Y | |||
| nystatin | NYSTATIN | CREAM (G) | Y | |||
| nystatin | NYSTATIN | OINT. (G) | Y | |||
| nystatin/triamcinolone acet | MYTREX | CREAM (G) | Y | |||
| nystatin/triamcinolone acet | N.T.A. | CREAM (G) | Y | |||
| nystatin/triamcinolone acet | MYCONEL | CREAM (G) | Y | |||
| nystatin/triamcinolone acet | NYSTATIN-TRIAMCINOLONE | CREAM (G) | Y | |||
| acetic ac/resorcino/salicyl ac | ANTIFUNGAL NAIL | TINCTURE | N | Pharmacy PA | ||
| butenafine HCl | BUTENAFINE HCL | CREAM (G) | N | Pharmacy PA | ||
| butenafine HCl | ATHLETE'S FOOT | CREAM (G) | N | Pharmacy PA | ||
| ciclopirox | CICLOPIROX | SHAMPOO | N | Pharmacy PA | ||
| ciclopirox olamine | CICLOPIROX | SUSPENSION | N | Pharmacy PA | ||
| ciclopirox olamine | LOPROX | SUSPENSION | N | Pharmacy PA | ||
| ciclopirox/skin cleanser no.28 | CICLODAN | COMBO. PKG | N | Pharmacy PA | ||
| ciclopirox/skin cleanser no.40 | LOPROX | COMBO. PKG | N | Pharmacy PA | ||
| ciclopirox/skin cleanser no.40 | LOPROX | KIT SS-CLN | N | Pharmacy PA | ||
| ciclopirox/urea/camph/men/euc | CICLOPIROX | SOLUTION | N | Pharmacy PA | ||
| ciclopirox/urea/camph/men/euc | CICLODAN | SOLUTION | N | Pharmacy PA | ||
| clotrimazole | ALEVAZOL | OINT. (G) | N | Pharmacy PA | ||
| clotrimazole | ATHLETE'S FOOT | SOLUTION | N | Pharmacy PA | ||
| clotrimazole | CLOTRIMAZOLE | SOLUTION | N | Pharmacy PA | ||
| clotrimazole | LASOLEX | SOLUTION | N | Pharmacy PA | ||
| clotrimazole/betamethasone dip | CLOTRIMAZOLE-BETAMETHASONE | LOTION | N | Pharmacy PA | ||
| econazole nitrate | ECONAZOLE NITRATE | CREAM (G) | N | Pharmacy PA | ||
| econazole nitrate | ECONAZOLE NITRATE | FOAM | N | Pharmacy PA | ||
| ketoconazole | KETOCONAZOLE | FOAM | N | Pharmacy PA | ||
| ketoconazole | KETODAN | FOAM | N | Pharmacy PA | ||
| ketoconazole/skin cleanser 28 | KETODAN | COMBO. PKG | N | Pharmacy PA | ||
| miconazole nitrate | ATHLETE'S FOOT SPRAY | AERO POWD | N | Pharmacy PA | ||
| miconazole nitrate | THERA ANTIFUNGAL | CREAM(ML) | N | Pharmacy PA | ||
| miconazole nitrate | LASOLEX AG | GEL (GRAM) | N | Pharmacy PA | ||
| miconazole nitrate | ALOE VESTA | OINT.(ML) | N | Pharmacy PA | ||
| miconazole nitrate/zinc ox/pet | VUSION | OINT. (G) | N | Pharmacy PA | ||
| miconazole nitrate/zinc ox/pet | MICONAZOLE-ZINC OXIDE-PETROLTM | OINT. (G) | N | Pharmacy PA | ||
| naftifine HCl | NAFTIFINE HCL | CREAM (G) | N | Pharmacy PA | ||
| naftifine HCl | NAFTIN | GEL (GRAM) | N | Pharmacy PA | ||
| naftifine HCl | NAFTIFINE HCL | GEL (GRAM) | N | Pharmacy PA | ||
| nystatin | NYSTATIN | POWDER | N | Pharmacy PA | ||
| nystatin | NYSTOP | POWDER | N | Pharmacy PA | ||
| nystatin | NYAMYC | POWDER | N | Pharmacy PA | ||
| nystatin | KLAYESTA | POWDER | N | Pharmacy PA | ||
| nystatin/triamcinolone acet | MYTREX | OINT. (G) | N | Pharmacy PA | ||
| nystatin/triamcinolone acet | N.T.A. | OINT. (G) | N | Pharmacy PA | ||
| nystatin/triamcinolone acet | NYSTATIN-TRIAMCINOLONE | OINT. (G) | N | Pharmacy PA | ||
| oxiconazole nitrate | OXICONAZOLE NITRATE | CREAM (G) | N | Pharmacy PA | ||
| oxiconazole nitrate | OXISTAT | LOTION | N | Pharmacy PA | ||
| sertaconazole nitrate | ERTACZO | CREAM (G) | N | Pharmacy PA | ||
| tavaborole | TAVABOROLE | SOL W/APPL | N | Pharmacy PA | ||
| terbinafine HCl | ATHLETE'S FOOT | CREAM (G) | N | Pharmacy PA | ||
| terbinafine HCl | TERBINAFINE | CREAM (G) | N | Pharmacy PA | ||
| tolnaftate | TOLNAFTATE | AERO POWD | N | Pharmacy PA | ||
| tolnaftate | ATHLETE'S FOOT | AERO POWD | N | Pharmacy PA | ||
| tolnaftate | ANTIFUNGAL CREAM | CREAM (G) | N | Pharmacy PA | ||
| tolnaftate | TOLNAFTATE | CREAM (G) | N | Pharmacy PA | ||
| tolnaftate | TRITOLNACIDE C | CREAM(ML) | N | Pharmacy PA | ||
| tolnaftate | TOLNAFTATE | POWDER | N | Pharmacy PA | ||
| tolnaftate | ANTIFUNGAL | SOLUTION | N | Pharmacy PA | ||
| tolnaftate | MYCOZYL AL | SOLUTION | N | Pharmacy PA | ||
| tolnaftate | TRITOLNACIDE S | SOLUTION | N | Pharmacy PA | ||
| tolnaftate | MICOTRIN AL | SOLUTION | N | Pharmacy PA | ||
| tolnaftate | MICOMITIN | SOLUTION | N | Pharmacy PA | ||
| tolnaftate | ATHLETE'S FOOT | SPRAY | N | Pharmacy PA | ||
| undecylenic ac/zinc undecylena | ANTIFUNGAL CREAM | CREAM (G) | N | Pharmacy PA | ||
| undecylenic ac/zinc undecylena | UNDEX-25 | OINT. (G) | N | Pharmacy PA | ||
| undecylenic acid | TRIPENICOL C | CREAM(ML) | N | Pharmacy PA | ||
| undecylenic acid | TRIPENICOL S | SOLUTION | N | Pharmacy PA | ||
| gentian violet/brgreen/proflav | TRIPLE DYE | MED. SWAB | ||||
| gentian violet/brilliant green | TRIPLE DYE | LIQUID |