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