Steroids, 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 | New Drug Evaluation |
|---|---|---|---|---|---|
| alclometasone dipropionate | ALCLOMETASONE DIPROPIONATE | CREAM (G) | Y | ||
| alclometasone dipropionate | ALCLOMETASONE DIPROPIONATE | OINT. (G) | Y | ||
| betamethasone dipropionate | BETAMETHASONE DIPROPIONATE | CREAM (G) | Y | ||
| betamethasone dipropionate | ALPHATREX | LOTION | Y | ||
| betamethasone dipropionate | BETAMETHASONE DIPROPIONATE | LOTION | Y | ||
| betamethasone dipropionate | ALPHATREX | OINT. (G) | Y | ||
| betamethasone dipropionate | BETAMETHASONE DIPROPIONATE | OINT. (G) | Y | ||
| betamethasone valerate | BETAMETHASONE VALERATE | CREAM (G) | Y | ||
| betamethasone valerate | BETATREX | CREAM (G) | Y | ||
| betamethasone valerate | BETAMETHASONE VALERATE | OINT. (G) | Y | ||
| betamethasone valerate | BETATREX | OINT. (G) | Y | ||
| betamethasone/propylene glyc | BETAMETHASONE DIPROP AUGMENTED | CREAM (G) | Y | ||
| clobetasol propionate | CLOBETASOL PROPIONATE | CREAM (G) | Y | ||
| clobetasol propionate | CLOBETASOL PROPIONATE | OINT. (G) | Y | ||
| clobetasol propionate | CLOBETASOL PROPIONATE | SOLUTION | Y | ||
| desonide | DESOWEN | CREAM (G) | Y | ||
| desonide | DESONIDE | CREAM (G) | Y | ||
| desonide | TRIDESILON | CREAM (G) | Y | ||
| desonide | DESONIDE | OINT. (G) | Y | ||
| desonide | TRIDESILON | OINT. (G) | Y | ||
| desoximetasone | DESOXIMETASONE | CREAM (G) | Y | ||
| desoximetasone | TOPICORT | CREAM (G) | Y | ||
| fluocinolone acetonide | SYNALAR | CREAM (G) | Y | ||
| fluocinolone acetonide | FLUOCINOLONE ACETONIDE | CREAM (G) | Y | ||
| fluocinolone acetonide | FLUOCINOLONE ACETONIDE | SOLUTION | Y | ||
| fluocinolone acetonide | SYNALAR | SOLUTION | Y | ||
| fluocinonide | FLUOCINONIDE | CREAM (G) | Y | ||
| fluocinonide | VANOS | CREAM (G) | Y | ||
| fluocinonide | FLUOCINONIDE | SOLUTION | Y | ||
| fluocinonide/emollient base | FLUOCINONIDE-E | CREAM (G) | Y | ||
| hydrocortisone | HYDROCORTISONE | CREAM (G) | Y | ||
| hydrocortisone | ANTI-ITCH | CREAM (G) | Y | ||
| hydrocortisone | HYDROCREAM | CREAM (G) | Y | ||
| hydrocortisone | CORTIZONE-10 PLUS | CREAM (G) | Y | ||
| hydrocortisone | ANTI-ITCH | CREAM (G) | Y | ||
| hydrocortisone | MONISTAT CARE | CREAM (G) | Y | ||
| hydrocortisone | CORTAID | CREAM (G) | Y | ||
| hydrocortisone | CORTISONE | CREAM (G) | Y | ||
| hydrocortisone | CORTIZONE FOR KIDS | CREAM (G) | Y | ||
| hydrocortisone | CORTIZONE-5 | CREAM (G) | Y | ||
| hydrocortisone | HYDROCORT | CREAM (G) | Y | ||
| hydrocortisone | HYDROCORTISONE | CREAM (G) | Y | ||
| hydrocortisone | NOBLE FORMULA HC | CREAM (G) | Y | ||
| hydrocortisone | CORTIZONE-10 | CREAM (G) | Y | ||
| hydrocortisone | PREPARATION H | CREAM (G) | Y | ||
| hydrocortisone | ITCH RELIEF | OINT. (G) | Y | ||
| hydrocortisone | HYDROCORTISONE | OINT. (G) | Y | ||
| hydrocortisone | HYCORT | OINT. (G) | Y | ||
| hydrocortisone | ANTI-ITCH | OINT. (G) | Y | ||
| hydrocortisone | AQUAPHOR ITCH RELIEF | OINT. (G) | Y | ||
| hydrocortisone | CORTIZONE-10 | OINT. (G) | Y | ||
| hydrocortisone | HYDROCORT | OINT. (G) | Y | ||
| hydrocortisone | HYDROCORTISONE | OINT. (G) | Y | ||
| hydrocortisone | HYDROCORTISONE ACETATE | OINT. (G) | Y | ||
| hydrocortisone acetate | HYDROCORTISONE ACETATE | CREAM (G) | Y | ||
| hydrocortisone acetate | VANICREAM HC | CREAM (G) | Y | ||
| hydrocortisone acetate | DERMAREST DRICORT | CREAM (G) | Y | ||
| hydrocortisone acetate | HYDROCORTISONE ACETATE | CREAM (G) | Y | ||
| hydrocortisone butyrate | HYDROCORTISONE BUTYRATE | SOLUTION | Y | ||
| triamcinolone acetonide | TRIAMCINOLONE ACETONIDE | CREAM (G) | Y | ||
| triamcinolone acetonide | TRIAMCINOLONE ACETONIDE | OINT. (G) | Y | ||
| amcinonide | AMCINONIDE | CREAM (G) | N | ||
| betamethasone dipropionate | DIPROSONE | AEROSOL | N | ||
| betamethasone dipropionate | BETAMETHASONE DIPROP AUGMENTED | GEL (GRAM) | N | ||
| betamethasone valerate | BETAMETHASONE VALERATE | FOAM | N | ||
| betamethasone valerate | BETAMETHASONE VALERATE | LOTION | N | ||
| betamethasone/propylene glyc | BETAMETHASONE DIPROP AUGMENTED | LOTION | N | ||
| betamethasone/propylene glyc | BETAMETHASONE DIPROP AUGMENTED | OINT. (G) | N | ||
| betamethasone/propylene glyc | DIPROLENE | OINT. (G) | N | ||
| clobetasol propionate | CLOBETASOL PROPIONATE | FOAM | N | ||
| clobetasol propionate | CLOBETASOL PROPIONATE | GEL (GRAM) | N | ||
| clobetasol propionate | CLOBETASOL PROPIONATE | LOTION | N | ||
| clobetasol propionate | CLOBETASOL PROPIONATE | SHAMPOO | N | ||
| clobetasol propionate | CLOBEX | SHAMPOO | N | ||
| clobetasol propionate | CLODAN | SHAMPOO | N | ||
| clobetasol propionate | CLOBETASOL PROPIONATE | SPRAY | N | ||
| clobetasol propionate | CLOBEX | SPRAY | N | ||
| clobetasol propionate/emoll | CLOBETASOL EMOLLIENT | CREAM (G) | N | ||
| clobetasol propionate/emoll | CLOBETASOL EMULSION | FOAM | N | ||
| clobetasol propionate/emoll | CLOBETASOL EMOLLIENT | FOAM | N | ||
| clobetasol propionate/emoll | TOVET EMOLLIENT | FOAM | N | ||
| clobetasol/emollient no.65 | TOVET KIT | COMBO. PKG | N | ||
| clobetasol/skin cleanser no.28 | CLODAN | KT SHM CLN | N | ||
| clocortolone pivalate | CLOCORTOLONE PIVALATE | CREAM (G) | N | ||
| clocortolone pivalate | CLODERM | CREAM (G) | N | ||
| desonide | DESONIDE | LOTION | N | ||
| desoximetasone | TOPICORT | GEL (GRAM) | N | ||
| desoximetasone | DESOXIMETASONE | GEL (GRAM) | N | ||
| desoximetasone | DESOXIMETASONE | OINT. (G) | N | ||
| desoximetasone | DESOXIMETASONE | SPRAY | N | ||
| diflorasone diacet/emollient | APEXICON E | CREAM (G) | N | ||
| diflorasone diacetate | DIFLORASONE DIACETATE | CREAM (G) | N | ||
| diflorasone diacetate | DIFLORASONE DIACETATE | OINT. (G) | N | ||
| fluocinolone acetonide | DERMA-SMOOTHE-FS | OIL | N | ||
| fluocinolone acetonide | FLUOCINOLONE ACETONIDE | OIL | N | ||
| fluocinolone acetonide | FLUOCINOLONE ACETONIDE | OINT. (G) | N | ||
| fluocinolone acetonide | SYNALAR | OINT. (G) | N | ||
| fluocinolone acetonide | CAPEX SHAMPOO | SHAMPOO | N | ||
| fluocinolone/emol comb no.65 | SYNALAR | CMB ONT CR | N | ||
| fluocinolone/emol comb no.65 | SYNALAR | CREAM (G) | N | ||
| fluocinolone/shower cap | DERMA-SMOOTHE-FS | OIL | N | ||
| fluocinolone/shower cap | FLUOCINOLONE ACETONIDE | OIL | N | ||
| fluocinolone/skin clnsr28 | SYNALAR TS | KIT | N | ||
| fluocinonide | FLUOCINONIDE | GEL (GRAM) | N | ||
| fluocinonide | FLUOCINONIDE | OINT. (G) | N | ||
| flurandrenolide | FLURANDRENOLIDE | LOTION | N | ||
| fluticasone propionate | FLUTICASONE PROPIONATE | CREAM (G) | N | ||
| fluticasone propionate | BESER | LOTION | N | ||
| fluticasone propionate | FLUTICASONE PROPIONATE | LOTION | N | ||
| fluticasone propionate | FLUTICASONE PROPIONATE | OINT. (G) | N | ||
| fluticasone/emollient no.65 | BESER KIT | KT LOTN CE | N | ||
| halcinonide | HALCINONIDE | CREAM (G) | N | ||
| halcinonide | HALOG | CREAM (G) | N | ||
| halcinonide | HALOG | OINT. (G) | N | ||
| halcinonide | HALCINONIDE | SOLUTION | N | ||
| halcinonide | HALOG | SOLUTION | N | ||
| halobetasol propionate | HALOBETASOL PROPIONATE | CREAM (G) | N | ||
| halobetasol propionate | LEXETTE | FOAM | N | ||
| halobetasol propionate | HALOBETASOL PROPIONATE | FOAM | N | ||
| halobetasol propionate | ULTRAVATE | LOTION | N | ||
| halobetasol propionate | BRYHALI | LOTION | N | ||
| halobetasol propionate | HALOBETASOL PROPIONATE | OINT. (G) | N | ||
| hydrocortisone | HYDROCORTISONE | CREAM PACK | N | ||
| hydrocortisone | SCALP CORT | LOTION | N | ||
| hydrocortisone | HYDROCORTISONE | LOTION | N | ||
| hydrocortisone | CETACORT | LOTION | N | ||
| hydrocortisone | TEXACORT | SOLUTION | N | ||
| hydrocortisone | SCALP | SOLUTION | N | ||
| hydrocortisone | HYDROCORTISONE | SPRAY | N | ||
| hydrocortisone acet/aloe vera | HYDROCORTISONE W/ALOE | CREAM (G) | N | ||
| hydrocortisone acet/aloe vera | HYDROCORTISONE ACETATE W/ALOE | CREAM (G) | N | ||
| hydrocortisone acet/aloe vera | HYDROCORTISONE ACETATE W/ALOE | OINT. (G) | N | ||
| hydrocortisone acet/aloe vera | HYDROCORTISONE W/ALOE | OINT. (G) | N | ||
| hydrocortisone acet/aloe vera | HYDROCORTISONE W/ALOE | PACKET | N | ||
| hydrocortisone acetate | HYDROCORTISONE | OINT. (G) | N | ||
| hydrocortisone acetate | HYDROCORTISONE ACETATE | OINT. (G) | N | ||
| hydrocortisone butyrate | HYDROCORTISONE BUTYRATE | CREAM (G) | N | ||
| hydrocortisone butyrate | LOCOID | LOTION | N | ||
| hydrocortisone butyrate | HYDROCORTISONE BUTYRATE | LOTION | N | ||
| hydrocortisone butyrate | HYDROCORTISONE BUTYRATE | OINT. (G) | N | ||
| hydrocortisone butyrate/emoll | LOCOID LIPOCREAM | CREAM (G) | N | ||
| hydrocortisone butyrate/emoll | HYDROCORTISONE BUTYRATE | CREAM (G) | N | ||
| hydrocortisone probutate | PANDEL | CREAM (G) | N | ||
| hydrocortisone valerate | HYDROCORTISONE VALERATE | CREAM (G) | N | ||
| hydrocortisone valerate | HYDROCORTISONE VALERATE | OINT. (G) | N | ||
| hydrocortisone/aloe vera | HYDROCORTISONE-ALOE | CREAM (G) | N | ||
| hydrocortisone/aloe vera | ITCH RELIEF WITH ALOE | CREAM (G) | N | ||
| hydrocortisone/aloe vera | HYDROCORTISONE W/ALOE | CREAM (G) | N | ||
| hydrocortisone/aloe vera | HYDROCORTISONE PLUS | CREAM (G) | N | ||
| hydrocortisone/aloe vera | HYDROCORTISONE W/ALOE | OINT. (G) | N | ||
| hydrocortisone/skin cleanser25 | AQUA GLYCOLIC HC | COMBO. PKG | N | ||
| mometasone furoate | MOMETASONE FUROATE | CREAM (G) | N | ||
| mometasone furoate | MOMETASONE FUROATE | OINT. (G) | N | ||
| mometasone furoate | MOMETASONE FUROATE | SOLUTION | N | ||
| neomycin sulfate/fluocinolone | NEO-SYNALAR | CREAM (G) | N | ||
| neomycin/fluocinolone/emoll 65 | NEO-SYNALAR | CREAM (G) | N | ||
| prednicarbate | PREDNICARBATE | OINT. (G) | N | ||
| triamcinolone acetonide | TRIAMCINOLONE ACETONIDE | AEROSOL | N | ||
| triamcinolone acetonide | TRIAMCINOLONE ACETONIDE | LOTION | N | ||
| triamcinolone acetonide | KENALOG | LOTION | N | ||
| hydrocortisone | PROCTO-MED HC | CRM/PE APP | |||
| hydrocortisone | PROCTOSOL-HC | CRM/PE APP | |||
| hydrocortisone | PROCTOZONE-HC | CRM/PE APP | |||
| hydrocortisone | HYDROCORTISONE | CRM/PE APP | |||
| hydrocortisone | ANUSOL-HC | CRM/PE APP | |||
| hydrocortisone | HYDROXYM | GEL (GRAM) | |||
| hydrocortisone/skin cleanser | HYDROCORTISONE LOTION COMPLETE | COMBO. PKG | |||
| neomycin sulfate/hydrocort | NEOMYCIN W/HYDROCORTISONE | OINT. (G) |