Topical Products for Inflammatory Skin Diseases

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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
Current Drug Use Criteria New Drug Evaluation
calcipotriene CALCIPOTRIENE CREAM (G) Y Age Restriction  
calcipotriene/betamethasone CALCIPOTRIENE-BETAMETHASONE OINT. (G) Y Age Restriction  
calcipotriene/betamethasone TACLONEX OINT. (G) Y Age Restriction  
pimecrolimus ELIDEL CREAM (G) Y Age Restriction  
pimecrolimus PIMECROLIMUS CREAM (G) Y Age Restriction  
tacrolimus PROTOPIC OINT. (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 CALCIPOTRIENE-BETAMETHASONE SUSPENSION N Age Restriction  
calcipotriene/betamethasone TACLONEX SUSPENSION N Age Restriction  
calcitriol CALCITRIOL OINT. (G) N Age Restriction  
coal tar DHS TAR GEL SHAMPOO N Age Restriction  
coal tar DHS TAR 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 PA Document  
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