Acne

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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 but eligible patients will encounter a co-pay at the pharmacy.
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
adapalene DIFFERIN CREAM (G) Y PA Document  
adapalene ADAPALENE CREAM (G) Y PA Document  
adapalene ADAPALENE GEL (GRAM) Y PA Document  
adapalene DIFFERIN GEL (GRAM) Y PA Document  
adapalene ADAPALENE GEL W/PUMP Y PA Document  
adapalene DIFFERIN GEL W/PUMP Y PA Document  
adapalene DIFFERIN LOTION Y PA Document  
adapalene/benzoyl peroxide EPIDUO GEL W/PUMP Y PA Document  
adapalene/benzoyl peroxide ADAPALENE-BENZOYL PEROXIDE GEL W/PUMP Y PA Document  
azelaic acid FINACEA GEL (GRAM) Y PA Document  
azelaic acid AZELAIC ACID GEL (GRAM) Y PA Document  
benzoyl peroxide BENZOYL PEROXIDE CLEANSER Y PA Document  
benzoyl peroxide PACNEX CLEANSER Y PA Document  
benzoyl peroxide BP WASH CLEANSER Y PA Document  
benzoyl peroxide BENZOYL PEROXIDE FOAM Y PA Document  
benzoyl peroxide BENZEPRO FOAM Y PA Document  
benzoyl peroxide BP FOAM FOAM Y PA Document  
benzoyl peroxide BENZAC W 10 GEL (GRAM) Y PA Document  
benzoyl peroxide BENZAC W 2.5 GEL (GRAM) Y PA Document  
benzoyl peroxide BENZAC W 5 GEL (GRAM) Y PA Document  
benzoyl peroxide BENZOYL PEROXIDE GEL (GRAM) Y PA Document  
benzoyl peroxide ACNE MEDICATION GEL (GRAM) Y PA Document  
benzoyl peroxide DEL-AQUA-5 GEL (GRAM) Y PA Document  
benzoyl peroxide PANOXYL AQ 5 GEL (GRAM) Y PA Document  
benzoyl peroxide BP GEL (GRAM) Y PA Document  
benzoyl peroxide PANOXYL AQ 2.5 GEL (GRAM) Y PA Document  
benzoyl peroxide ACNE MEDICATION GEL (GRAM) Y PA Document  
benzoyl peroxide ACNE TREATMENT GEL (GRAM) Y PA Document  
benzoyl peroxide ACNECLEAR GEL (GRAM) Y PA Document  
benzoyl peroxide BENZOYL PEROXIDE GEL (GRAM) Y PA Document  
benzoyl peroxide PERSA-GEL GEL (GRAM) Y PA Document  
benzoyl peroxide BPO TOWELETTE Y PA Document  
clindamycin phos/benzoyl perox BENZACLIN GEL (GRAM) Y PA Document  
clindamycin phos/benzoyl perox CLINDAMYCIN PHOS-BENZOYL PEROX GEL (GRAM) Y PA Document  
clindamycin phos/benzoyl perox CLINDAMYCIN-BENZOYL PEROXIDE GEL (GRAM) Y PA Document  
clindamycin phos/benzoyl perox DUAC GEL (GRAM) Y PA Document  
clindamycin phos/benzoyl perox NEUAC GEL (GRAM) Y PA Document  
clindamycin phos/benzoyl perox ACANYA GEL W/PUMP Y PA Document  
clindamycin phos/benzoyl perox BENZACLIN GEL W/PUMP Y PA Document  
clindamycin phos/benzoyl perox CLINDAMYCIN PHOS-BENZOYL PEROX GEL W/PUMP Y PA Document  
clindamycin phos/benzoyl perox CLINDAMYCIN-BENZOYL PEROXIDE GEL W/PUMP Y PA Document  
clindamycin phosphate EVOCLIN FOAM Y PA Document  
clindamycin phosphate CLINDAMYCIN PHOSPHATE FOAM Y PA Document  
clindamycin phosphate CLEOCIN T GEL (GRAM) Y PA Document  
clindamycin phosphate CLINDAMYCIN PHOSPHATE GEL (GRAM) Y PA Document  
clindamycin phosphate CLEOCIN T LOTION Y PA Document  
clindamycin phosphate CLINDAMYCIN PHOSPHATE LOTION Y PA Document  
clindamycin phosphate CLINDAMYCIN PHOSPHATE MED. SWAB Y PA Document  
clindamycin phosphate CLEOCIN T MED. SWAB Y PA Document  
clindamycin phosphate CLINDACIN ETZ MED. SWAB Y PA Document  
clindamycin phosphate CLINDACIN P MED. SWAB Y PA Document  
clindamycin phosphate CLINDAMYCIN PHOSPHATE SOLUTION Y PA Document  
clindamycin/tretinoin CLINDAMYCIN PHOS-TRETINOIN GEL (GRAM) Y PA Document  
clindamycin/tretinoin ZIANA GEL (GRAM) Y PA Document  
dapsone ACZONE GEL (GRAM) Y PA Document  
dapsone DAPSONE GEL (GRAM) Y PA Document  
erythromycin base in ethanol ERYGEL GEL (GRAM) Y PA Document  
erythromycin base in ethanol ERYTHROMYCIN GEL (GRAM) Y PA Document  
erythromycin base in ethanol ERY MED. SWAB Y PA Document  
erythromycin base in ethanol ERYTHROMYCIN MED. SWAB Y PA Document  
erythromycin base in ethanol ERYTHROMYCIN SOLUTION Y PA Document  
isotretinoin MYORISAN CAPSULE Y PA Document  
isotretinoin ABSORICA CAPSULE Y PA Document  
isotretinoin AMNESTEEM CAPSULE Y PA Document  
isotretinoin CLARAVIS CAPSULE Y PA Document  
isotretinoin ISOTRETINOIN CAPSULE Y PA Document  
isotretinoin ZENATANE CAPSULE Y PA Document  
sulfacetamide sodium SULFACETAMIDE SODIUM SUSPENSION Y PA Document  
sulfacetamide sodium KLARON SUSPENSION Y PA Document  
tretinoin AVITA CREAM (G) Y PA Document  
tretinoin TRETINOIN CREAM (G) Y PA Document  
tretinoin RETIN-A CREAM (G) Y PA Document  
tretinoin TRETINOIN GEL (GRAM) Y PA Document  
tretinoin RETIN-A GEL (GRAM) Y PA Document  
tretinoin AVITA GEL (GRAM) Y PA Document  
tretinoin ATRALIN GEL (GRAM) Y PA Document  
tretinoin microspheres TRETINOIN MICROSPHERE GEL (GRAM) Y PA Document  
tretinoin microspheres RETIN-A MICRO GEL (GRAM) Y PA Document  
tretinoin microspheres RETIN-A MICRO PUMP GEL W/PUMP Y PA Document  
tretinoin microspheres TRETINOIN MICROSPHERE GEL W/PUMP Y PA Document  
adapalene PLIXDA MED. SWAB N PA Document  
adapalene ADAPALENE SOLUTION N PA Document  
adapalene/benzoyl peroxide EPIDUO FORTE GEL W/PUMP N PA Document  
azelaic acid FINEVIN CREAM (G) N PA Document  
azelaic acid AZELEX CREAM (G) N PA Document  
azelaic acid FINACEA FOAM N PA Document Mar 31, 2016
benzoyl peroxide PANOXYL-4 CLEANSER N PA Document  
benzoyl peroxide BPO GEL (GRAM) N PA Document  
clindamycin phos/benzoyl perox ONEXTON GEL (GRAM) N PA Document  
clindamycin phos/benzoyl perox ONEXTON GEL W/PUMP N PA Document  
clindamycin phos/skin clnsr 19 CLINDACIN ETZ KIT N PA Document  
clindamycin phos/skin clnsr 19 CLINDACIN PAC KIT N PA Document  
clindamycin/benzoyl/emol cmb94 NEUAC CMB CR GEL N PA Document  
dapsone ACZONE GEL W/PUMP N PA Document  
erythromycin base DEL-MYCIN SOLUTION N PA Document  
erythromycin/benzoyl peroxide BENZAMYCINPAK GEL (EA) N PA Document  
erythromycin/benzoyl peroxide BENZAMYCIN GEL (GRAM) N PA Document  
erythromycin/benzoyl peroxide ERYTHROMYCIN-BENZOYL PEROXIDE GEL (GRAM) N PA Document  
isotretinoin ABSORICA CAPSULE N PA Document  
tazarotene FABIOR FOAM N PA Document  
tretinoin TRETIN-X CREAM (G) N PA Document  
tretinoin microspheres RETIN-A MICRO PUMP GEL W/PUMP N PA Document  
tretinoin/emol 9/skin cleansr1 TRETIN-X COMBO. PKG N PA Document  
tretinoin TRETINOIN CREAM (G) PA Document