Herpes Simplex
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 |
|---|---|---|---|---|---|---|
| acyclovir | ACYCLOVIR | CAPSULE | Y | N | ||
| acyclovir | ACYCLOVIR | ORAL SUSP | Y | N | ||
| acyclovir | ACYCLOVIR | TABLET | Y | N | ||
| valacyclovir HCl | VALTREX | TABLET | Y | N | ||
| valacyclovir HCl | VALACYCLOVIR | TABLET | Y | N | ||
| acyclovir | ACYCLOVIR | CREAM (G) | N | Pharmacy PA | N | |
| acyclovir | SITAVIG | MA BUC TAB | N | Pharmacy PA | N | |
| acyclovir | ACYCLOVIR | OINT. (G) | N | Pharmacy PA | N | |
| docosanol | DOCOSANOL | CREAM (G) | N | Pharmacy PA | N | |
| famciclovir | FAMCICLOVIR | TABLET | N | Pharmacy PA | N | |
| penciclovir | DENAVIR | CREAM (G) | N | Pharmacy PA | N | |
| penciclovir | PENCICLOVIR | CREAM (G) | N | Pharmacy PA | N |