Antipsoriatics, 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 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 |
|---|---|---|---|---|---|
| calcipotriene | DOVONEX | CREAM (G) | Y | PA Document | |
| calcipotriene | CALCIPOTRIENE | CREAM (G) | Y | PA Document | |
| calcipotriene | CALCIPOTRIENE | SOLUTION | Y | PA Document | |
| calcipotriene/betamethasone | CALCIPOTRIENE-BETAMETHASONE DP | OINT. (G) | Y | PA Document | |
| calcipotriene/betamethasone | TACLONEX | OINT. (G) | Y | PA Document | |
| tazarotene | TAZORAC | CREAM (G) | Y | PA Document | |
| tazarotene | TAZAROTENE | CREAM (G) | Y | PA Document | |
| tazarotene | TAZORAC | GEL (GRAM) | Y | PA Document | |
| anthralin | ANTHRALIN | CREAM (G) | N | PA Document | |
| calcipotriene | SORILUX | FOAM | N | PA Document | |
| calcipotriene | CALCITRENE | OINT. (G) | N | PA Document | |
| calcipotriene | CALCIPOTRIENE | OINT. (G) | N | PA Document | |
| calcipotriene/betamethasone | ENSTILAR | FOAM | N | PA Document | |
| calcipotriene/betamethasone | TACLONEX | SUSPENSION | N | PA Document | |
| calcitriol | VECTICAL | OINT. (G) | N | PA Document | |
| calcitriol | CALCITRIOL | OINT. (G) | N | PA Document | |
| coal tar | SCYTERA | FOAM | N | PA Document | |
| coal tar | PSORIATAR | FOAM | N | PA Document | |
| coal tar | OXIPOR VHC | LOTION | N | PA Document | |
| coal tar | DHS TAR GEL | SHAMPOO | N | PA Document | |
| coal tar | THERA-GEL | SHAMPOO | N | PA Document | |
| coal tar | POLYTAR | SHAMPOO | N | PA Document | |
| coal tar | IONIL T | SHAMPOO | N | PA Document | |
| coal tar | DHS TAR | SHAMPOO | N | PA Document | |
| coal tar | ANTI-DANDRUFF | SHAMPOO | N | PA Document | |
| tazarotene | AVAGE | CREAM (G) | N | PA Document | |
| halobetasol propion/tazarotene | DUOBRII | LOTION | PA Document |