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 |
|---|---|---|---|---|---|---|
| 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 |