Antifungals, Vaginal
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 |
---|---|---|---|---|---|
butoconazole nitrate | GYNAZOLE 1 | CRM/PF APP | |||
clotrimazole | VAGINAL 3-DAY | COMBO. PKG | |||
clotrimazole | CLOTRIMAZOLE-3 | CREAM/APPL | |||
clotrimazole | 3-DAY VAGINAL CREAM | CREAM/APPL | |||
clotrimazole | CLOTRIMAZOLE | CREAM/APPL | |||
clotrimazole | CLOTRIMAZOLE | TABLET | |||
miconazole nitrate | MICONAZOLE 3 | CMB PF CRM | |||
miconazole nitrate | MICONAZOLE 7 | CREAM/APPL | |||
miconazole nitrate | MICONAZOLE NITRATE | CREAM/APPL | |||
miconazole nitrate | MICONAZOLE-7 | CREAM/APPL | |||
miconazole nitrate | YEAST-X | CREAM/APPL | |||
miconazole nitrate | MICONAZOLE 3 | KIT | |||
miconazole nitrate | MICONAZOLE 1 | KIT | |||
miconazole nitrate | MICONAZOLE 7 | SUPP.VAG | |||
miconazole nitrate | MICONAZOLE NITRATE | SUPP.VAG | |||
miconazole nitrate | MICONAZOLE 3 | SUPP.VAG | |||
pulsatilla | YEAST-X | SUPP.VAG | |||
terconazole | TERCONAZOLE | CREAM/APPL | |||
terconazole | TERCONAZOLE | SUPP.VAG | |||
tioconazole | TIOCONAZOLE-1 | OIN/PF APP |