Topical Products for Inflammatory Skin Diseases
PDL Reference Documents
- Topicals for Inflammatory Skin Conditions - Dec 01, 2022
- Therapeutics for Atopic Dermatitis and Inflammatory Skin Conditions - Jun 02, 2022
- Vitiligo Literature Scan - Jun 02, 2022
- Atopic Dermatitis - Oct 01, 2020
- Dupixent (dupilumab) Indication Update - Nov 21, 2019
- Atopic Dermatitis - Jul 25, 2019
- Atopic Dermatitis - Mar 22, 2018
- Topical Antipsoriatics Literature Scan - Sep 28, 2017
- Topical Psoriasis Literature Scan - Jan 29, 2015
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 |
|---|---|---|---|---|---|
| calcipotriene | CALCIPOTRIENE | CREAM (G) | Y | Age Restriction | |
| calcipotriene/betamethasone | TACLONEX | OINT. (G) | Y | Age Restriction | |
| calcipotriene/betamethasone | CALCIPOTRIENE-BETAMETHASONE | OINT. (G) | Y | Age Restriction | |
| pimecrolimus | PIMECROLIMUS | CREAM (G) | Y | Age Restriction | |
| pimecrolimus | ELIDEL | CREAM (G) | Y | Age Restriction | |
| tacrolimus | TACROLIMUS | OINT. (G) | Y | Age Restriction | |
| tazarotene | TAZAROTENE | CREAM (G) | Y | Age Restriction | |
| anthralin | ANTHRALIN | CREAM (G) | N | Age Restriction | |
| calcipotriene | SORILUX | FOAM | N | Age Restriction | |
| calcipotriene | CALCIPOTRIENE | FOAM | N | Age Restriction | |
| calcipotriene | CALCIPOTRIENE | OINT. (G) | N | Age Restriction | |
| calcipotriene/betamethasone | ENSTILAR | FOAM | N | Age Restriction | |
| calcipotriene/betamethasone | TACLONEX | SUSPENSION | N | Age Restriction | |
| calcipotriene/betamethasone | CALCIPOTRIENE-BETAMETHASONE | SUSPENSION | N | Age Restriction | |
| calcitriol | CALCITRIOL | OINT. (G) | N | Age Restriction | |
| calcitriol | VECTICAL | OINT. (G) | N | Age Restriction | |
| coal tar | DHS TAR | SHAMPOO | N | Age Restriction | |
| coal tar | DHS TAR GEL | SHAMPOO | N | Age Restriction | |
| coal tar | IONIL T | SHAMPOO | N | Age Restriction | |
| coal tar | THERA-GEL | SHAMPOO | N | Age Restriction | |
| crisaborole | EUCRISA | OINT. (G) | N | Age Restriction | May 25, 2017 |
| halobetasol propion/tazarotene | DUOBRII | LOTION | N | Age Restriction | |
| roflumilast | ZORYVE | CREAM (G) | N | Age Restriction | |
| roflumilast | ZORYVE | FOAM | N | Age Restriction | |
| ruxolitinib phosphate | OPZELURA | CREAM (G) | N | Age Restriction | |
| tapinarof | VTAMA | CREAM (G) | N | Age Restriction | |
| tazarotene | FABIOR | FOAM | N | ||
| tazarotene | TAZAROTENE | FOAM | N | ||
| tazarotene | TAZAROTENE | GEL (GRAM) | N | Age Restriction | |
| tazarotene | ARAZLO | LOTION | N | ||
| sirolimus | HYFTOR | GEL (GRAM) | Age Restriction |