Topical Products for Inflammatory Skin Diseases
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 |
|---|---|---|---|---|---|---|
| tacrolimus | TACROLIMUS | OINT. (G) | Y | Age Restriction | N | |
| anthralin | ANTHRALIN | CREAM (G) | N | Age Restriction | N | |
| calcipotriene | SORILUX | FOAM | N | Age Restriction | N | |
| calcipotriene | CALCIPOTRIENE | FOAM | N | Age Restriction | N | |
| calcipotriene/betamethasone | ENSTILAR | FOAM | N | Age Restriction | N | |
| calcipotriene/betamethasone | CALCIPOTRIENE-BETAMETHASONE | SUSPENSION | N | Age Restriction | N | |
| calcitriol | CALCITRIOL | OINT. (G) | N | Age Restriction | N | |
| coal tar | THERA-GEL | SHAMPOO | N | Age Restriction | N | |
| coal tar | DHS TAR | SHAMPOO | N | Age Restriction | N | |
| coal tar | T-PLUS | SHAMPOO | N | Age Restriction | N | |
| roflumilast | ZORYVE | CREAM (G) | N | Age Restriction | N | |
| roflumilast | ZORYVE | FOAM | N | Age Restriction | N | |
| tapinarof | VTAMA | CREAM (G) | N | Age Restriction | N | |
| tazarotene | TAZAROTENE | FOAM | N | N |