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 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
miconazole nitrate MICONAZOLE NITRATE CREAM (G) Y    
miconazole nitrate INZO ANTIFUNGAL CREAM (G) Y    
miconazole nitrate ANTIFUNGAL CREAM CREAM (G) Y    
miconazole nitrate INZO ANTIFUNGAL CREAM (G) Y    
miconazole nitrate ANTIFUNGAL CREAM CREAM (G) Y    
miconazole nitrate MICATIN CREAM (G) Y    
miconazole nitrate BAZA ANTIFUNGAL CREAM (G) Y    
miconazole nitrate ANTI-FUNGAL CREAM CREAM (G) Y    
miconazole nitrate MICONAZOLE NITRATE CREAM (G) Y    
nystatin NYSTATIN CREAM (G) Y    
nystatin NYSTATIN OINT. (G) Y    
nystatin NYSTATIN POWDER Y 5 billion unit, 100,000 unit/gram, 100,000 unit/gram, 5 billion unit Require PA  
acetic ac/resorcino/salicyl ac ANTIFUNGAL NAIL TINCTURE N PA Document  
butenafine HCl MENTAX CREAM (G) N PA Document  
butenafine HCl BUTENAFINE HCL CREAM (G) N PA Document  
ciclopirox CICLOPIROX GEL (GRAM) N PA Document  
ciclopirox LOPROX SHAMPOO N PA Document  
ciclopirox CICLOPIROX SHAMPOO N PA Document  
ciclopirox PENLAC SOLUTION N PA Document  
ciclopirox CICLOPIROX SOLUTION N PA Document  
ciclopirox CICLODAN SOLUTION N PA Document  
ciclopirox olamine CICLOPIROX CREAM (G) N PA Document  
ciclopirox olamine LOPROX 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 DESENEX 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 ALEVAZOL OINT. (G) N PA Document  
clotrimazole CLOTRIMAZOLE SOLUTION N PA Document  
clotrimazole FUNGOID SOLUTION N PA Document  
clotrimazole/betameth dip/zinc DERMACINRX THERAZOLE PAK COMBO. PKG N PA Document  
clotrimazole/betamethasone dip CLOTRIMAZOLE-BETAMETHASONE CREAM (G) N PA Document  
clotrimazole/betamethasone dip LOTRISONE 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 KETOCONAZOLE FOAM N PA Document  
ketoconazole EXTINA FOAM N PA Document  
ketoconazole NIZORAL SHAMPOO N PA Document  
ketoconazole KETOCONAZOLE SHAMPOO N PA Document  
luliconazole LULICONAZOLE CREAM (G) N PA Document  
luliconazole LUZU CREAM (G) N PA Document  
miconazole nitrate ATHLETE'S FOOT SPRAY AERO POWD N PA Document  
miconazole nitrate REMEDY ANTIFUNGAL CREAM(ML) N PA Document  
miconazole nitrate FUNGOID TINCTURE KIT N PA Document  
miconazole nitrate REMEDY PHYTOPLEX ANTIFUNGAL OINT. (G) N PA Document  
miconazole nitrate ALOE VESTA OINT. (G) N PA Document  
miconazole nitrate ALOE VESTA OINT.(ML) N PA Document  
miconazole nitrate ZEASORB AF POWDER N PA Document  
miconazole nitrate REMEDY PHYTOPLEX ANTIFUNGAL POWDER N PA Document  
miconazole nitrate MICONAZORB AF POWDER N PA Document  
miconazole nitrate ZEASORB POWDER N PA Document  
miconazole nitrate DESENEX POWDER N PA Document  
miconazole nitrate ANTIFUNGAL POWDER POWDER 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 CREAM (G) N PA Document  
naftifine HCl NAFTIN GEL (GRAM) N PA Document  
nystatin NYSTOP POWDER N PA Document  
nystatin NYATA POWDER N PA Document  
nystatin NYAMYC POWDER N PA Document  
nystatin/emollient combo no.54 PEDIADERM AF CREAM (G) N PA Document  
nystatin/emollient combo no.88 NYATA CMB GEL PD N PA Document  
nystatin/triamcin NYSTATIN W/TRIAMCINOLONE CREAM (G) N PA Document  
nystatin/triamcin MYCONEL CREAM (G) N PA Document  
nystatin/triamcin MYTREX CREAM (G) N PA Document  
nystatin/triamcin NYSTATIN-TRIAMCINOLONE CREAM (G) N PA Document  
nystatin/triamcin N.T.A. CREAM (G) N PA Document  
nystatin/triamcin MYTREX OINT. (G) N PA Document  
nystatin/triamcin NYSTATIN-TRIAMCINOLONE OINT. (G) N PA Document  
nystatin/triamcin N.T.A. OINT. (G) N PA Document  
oxiconazole nitrate OXICONAZOLE NITRATE CREAM (G) N PA Document  
oxiconazole nitrate OXISTAT CREAM (G) N PA Document  
oxiconazole nitrate OXISTAT LOTION N PA Document  
sertaconazole nitrate ERTACZO CREAM (G) N PA Document  
sulconazole nitrate EXELDERM CREAM (G) N PA Document  
sulconazole nitrate EXELDERM SOLUTION N PA Document  
tavaborole KERYDIN SOL W/APPL N PA Document  
terbinafine LAMISIL AT GEL (GRAM) N PA Document  
terbinafine HCl ATHLETE'S FOOT CREAM (G) N PA Document  
terbinafine HCl TERBINAFINE CREAM (G) N PA Document  
terbinafine HCl LAMISIL AT CREAM (G) N PA Document  
terbinafine HCl ATHLETE'S FOOT AF CREAM (G) N PA Document  
terbinafine HCl LAMISIL SPRAY N PA Document  
tolnaftate ATHLETE'S FOOT AERO POWD N PA Document  
tolnaftate TOLNAFTATE AERO POWD N PA Document  
tolnaftate LAMISIL AF AERO POWD N PA Document  
tolnaftate JOCK ITCH AERO POWD N PA Document  
tolnaftate TOLNAFTATE CREAM (G) N PA Document  
tolnaftate FUNGOID-D CREAM (G) N PA Document  
tolnaftate ANTIFUNGAL CREAM CREAM (G) N PA Document  
tolnaftate TOLNAFTATE POWDER N PA Document  
tolnaftate LAMISIL AF POWDER N PA Document  
tolnaftate ANTI-FUNGAL POWDER N PA Document  
tolnaftate ATHLETE'S FOOT SPRAY 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  
gentian violet GENTIAN VIOLET SOLUTION    
gentian violet/brgreen/proflav TRIPLE DYE MED. SWAB    
gentian violet/brilliant green TRIPLE DYE LIQUID