Acne
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 |
|---|---|---|---|---|---|---|
| adapalene | ADAPALENE | GEL (GRAM) | Y | Pharmacy PA | N | |
| adapalene | ADAPALENE | GEL (GRAM) | Y | Pharmacy PA | N | |
| adapalene | DIFFERIN | GEL W/PUMP | Y | Pharmacy PA | N | |
| azelaic acid | AZELAIC ACID | GEL (GRAM) | Y | Pharmacy PA | N | |
| benzoyl peroxide | BENZOYL PEROXIDE | CLEANSER | Y | Pharmacy PA | N | |
| benzoyl peroxide | ACNE FOAMING WASH | CLEANSER | Y | Pharmacy PA | N | |
| benzoyl peroxide | BENZOYL PEROXIDE | CLEANSER | Y | Pharmacy PA | N | |
| benzoyl peroxide | BP WASH | CLEANSER | Y | Pharmacy PA | N | |
| benzoyl peroxide | PANOXYL | CLEANSER | Y | Pharmacy PA | N | |
| benzoyl peroxide | BENZOYL PEROXIDE | GEL (GRAM) | Y | Pharmacy PA | N | |
| benzoyl peroxide | ACNE MEDICATION | GEL (GRAM) | Y | Pharmacy PA | N | |
| benzoyl peroxide | BENZAC W 5 | GEL (GRAM) | Y | Pharmacy PA | N | |
| benzoyl peroxide | ACNECLEAR | GEL (GRAM) | Y | Pharmacy PA | N | |
| benzoyl peroxide | DAYLOGIC ACNE TREATMENT | GEL (GRAM) | Y | Pharmacy PA | N | |
| benzoyl peroxide | BENZOYL PEROXIDE | GEL (GRAM) | Y | Pharmacy PA | N | |
| benzoyl peroxide | BENZOYL PEROXIDE | LOTION | Y | Pharmacy PA | N | |
| clindamycin phos/benzoyl perox | CLINDAMYCIN-BENZOYL PEROXIDE | GEL (GRAM) | Y | Pharmacy PA | N | |
| clindamycin phos/benzoyl perox | CLINDAMYCIN PHOS-BENZOYL PEROX | GEL (GRAM) | Y | Pharmacy PA | N | |
| clindamycin phos/benzoyl perox | CLINDAMYCIN-BENZOYL PEROXIDE | GEL W/PUMP | Y | Pharmacy PA | N | |
| clindamycin phosphate | CLINDACIN | FOAM | Y | Pharmacy PA | N | |
| clindamycin phosphate | CLINDAMYCIN PHOSPHATE | GEL (GRAM) | Y | Pharmacy PA | N | |
| clindamycin phosphate | CLINDAMYCIN PHOSPHATE | LOTION | Y | Pharmacy PA | N | |
| clindamycin phosphate | CLINDACIN P | MED. SWAB | Y | Pharmacy PA | N | |
| clindamycin/tretinoin | CLINDAMYCIN PHOS-TRETINOIN | GEL (GRAM) | Y | Pharmacy PA | N | |
| dapsone | DAPSONE | GEL (GRAM) | Y | Pharmacy PA | N | |
| erythromycin base in ethanol | ERY | MED. SWAB | Y | Pharmacy PA | N | |
| erythromycin base in ethanol | ERYTHROMYCIN | SOLUTION | Y | Pharmacy PA | N | |
| isotretinoin | CLARAVIS | CAPSULE | Y | Pharmacy PA | N | |
| isotretinoin | ISOTRETINOIN | CAPSULE | Y | Pharmacy PA | N | |
| isotretinoin | ABSORICA | CAPSULE | Y | Pharmacy PA | N | |
| sulfacetamide sodium | SULFACETAMIDE SODIUM | SUSPENSION | Y | Pharmacy PA | N | |
| tretinoin | TRETINOIN | GEL (GRAM) | Y | Pharmacy PA | N | |
| adapalene/benzoyl peroxide | EPIDUO FORTE | GEL W/PUMP | N | Pharmacy PA | N | |
| adapalene/benzoyl peroxide | ADAPALENE-BENZOYL PEROXIDE | GEL W/PUMP | N | Pharmacy PA | N | |
| azelaic acid | FINACEA | FOAM | N | Pharmacy PA | N | Mar 31, 2016 |
| clindamycin phos/skin clnsr 19 | CLINDACIN ETZ | KIT | N | Pharmacy PA | N | |
| dapsone | DAPSONE | GEL (GRAM) | N | Pharmacy PA | N | |
| isotretinoin | ABSORICA | CAPSULE | N | Pharmacy PA | N | |
| isotretinoin, micronized | ABSORICA LD | CAPSULE | N | Pharmacy PA | N | |
| tazarotene | FABIOR | FOAM | N | Pharmacy PA | N | |
| tazarotene | TAZAROTENE | FOAM | N | Pharmacy PA | N | |
| tretinoin/benzoyl peroxide | TWYNEO | CREAM (G) | N | Pharmacy PA | N | |
| benzoyl peroxide | EPSOLAY | CREAM (G) | Pharmacy PA | N | ||
| salicylic acid | DERMACINRX ATRIX | LIQUID | Pharmacy PA | N |