Acne and Rosacea

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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.
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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
adapalene DIFFERIN CREAM (G) Y    
adapalene ADAPALENE CREAM (G) Y    
adapalene DIFFERIN GEL (GRAM) Y    
adapalene ADAPALENE GEL (GRAM) Y    
adapalene PANOXYL GEL (GRAM) Y    
adapalene EFFACLAR ADAPALENE GEL (GRAM) Y    
adapalene ADAPALENE GEL (GRAM) Y    
adapalene ADAPALENE GEL W/PUMP Y    
adapalene DIFFERIN GEL W/PUMP Y    
adapalene DIFFERIN LOTION Y    
adapalene/benzoyl peroxide ADAPALENE-BENZOYL PEROXIDE GEL W/PUMP Y    
azelaic acid AZELAIC ACID GEL (GRAM) Y    
benzoyl peroxide BP WASH CLEANSER Y    
benzoyl peroxide DAYLOGIC ACNE FOAMING WASH CLEANSER Y    
benzoyl peroxide FOAMING ACNE FACE WASH CLEANSER Y    
benzoyl peroxide PANOXYL CLEANSER Y    
benzoyl peroxide BENZOYL PEROXIDE CLEANSER Y    
benzoyl peroxide PANOXYL CLEANSER Y    
benzoyl peroxide BENZOYL PEROXIDE CLEANSER Y    
benzoyl peroxide ACNE FOAMING WASH CLEANSER Y    
benzoyl peroxide ADVANCED EXFOLIATING CLEANSER CLEANSER Y    
benzoyl peroxide ACNE CONTROL CLEANSER CLEANSER Y    
benzoyl peroxide BENZEPRO FOAM Y    
benzoyl peroxide DAYLOGIC ACNE TREATMENT GEL (GRAM) Y    
benzoyl peroxide PERSA-GEL GEL (GRAM) Y    
benzoyl peroxide ACNE MEDICATION GEL (GRAM) Y    
benzoyl peroxide BENZOYL PEROXIDE GEL (GRAM) Y    
benzoyl peroxide BENZOYL PEROXIDE GEL (GRAM) Y    
benzoyl peroxide BENZAC W 5 GEL (GRAM) Y    
benzoyl peroxide BENZAC W 2.5 GEL (GRAM) Y    
benzoyl peroxide BENZAC W 10 GEL (GRAM) Y    
benzoyl peroxide ACNECLEAR GEL (GRAM) Y    
benzoyl peroxide ACNE MEDICATION GEL (GRAM) Y    
benzoyl peroxide ACNE TREATMENT GEL (GRAM) Y    
benzoyl peroxide ACNE MEDICATION LOTION Y    
benzoyl peroxide BENZOYL PEROXIDE LOTION Y    
benzoyl peroxide BENZOYL PEROXIDE LOTION Y    
clindamycin phos/benzoyl perox CLINDAMYCIN-BENZOYL PEROXIDE GEL (GRAM) Y    
clindamycin phos/benzoyl perox CLINDAMYCIN PHOS-BENZOYL PEROX GEL (GRAM) Y    
clindamycin phos/benzoyl perox NEUAC GEL (GRAM) Y    
clindamycin phos/benzoyl perox CLINDAMYCIN PHOS-BENZOYL PEROX GEL W/PUMP Y    
clindamycin phos/benzoyl perox CLINDAMYCIN-BENZOYL PEROXIDE GEL W/PUMP Y    
clindamycin phosphate CLINDAMYCIN PHOSPHATE FOAM Y    
clindamycin phosphate CLINDACIN FOAM Y    
clindamycin phosphate CLINDAMYCIN PHOSPHATE GEL (GRAM) Y    
clindamycin phosphate CLINDAMYCIN PHOSPHATE LOTION Y    
clindamycin phosphate CLEOCIN T LOTION Y    
clindamycin phosphate CLINDAMYCIN PHOSPHATE MED. SWAB Y    
clindamycin phosphate CLINDACIN P MED. SWAB Y    
clindamycin phosphate CLINDACIN ETZ MED. SWAB Y    
clindamycin phosphate CLINDAMYCIN PHOSPHATE SOLUTION Y    
clindamycin/tretinoin CLINDAMYCIN PHOS-TRETINOIN GEL (GRAM) Y    
dapsone DAPSONE GEL (GRAM) Y    
erythromycin base in ethanol ERYTHROMYCIN GEL (GRAM) Y    
erythromycin base in ethanol ERY MED. SWAB Y    
erythromycin base in ethanol ERYTHROMYCIN SOLUTION Y    
erythromycin/benzoyl peroxide ERYTHROMYCIN-BENZOYL PEROXIDE GEL (GRAM) Y    
isotretinoin CLARAVIS CAPSULE Y    
isotretinoin AMNESTEEM CAPSULE Y    
isotretinoin ABSORICA CAPSULE Y    
isotretinoin ISOTRETINOIN CAPSULE Y    
isotretinoin ZENATANE CAPSULE Y    
sulfacetamide sodium SULFACETAMIDE SODIUM SUSPENSION Y    
tretinoin TRETINOIN CREAM (G) Y    
tretinoin TRETINOIN GEL (GRAM) Y    
adapalene/benzoyl peroxide ADAPALENE-BENZOYL PEROXIDE GEL W/PUMP N Pharmacy PA  
adapalene/benzoyl peroxide EPIDUO FORTE GEL W/PUMP N Pharmacy PA  
azelaic acid FINEVIN CREAM (G) N Pharmacy PA  
azelaic acid FINACEA FOAM N Pharmacy PA Mar 31, 2016
benzoyl peroxide BENZOYL PEROXIDE CLEANSER N Pharmacy PA  
benzoyl peroxide BPO TOWELETTE N Pharmacy PA  
clascoterone WINLEVI CREAM (G) N Pharmacy PA  
clindamycin phos/benzoyl perox CLINDAMYCIN-BENZOYL PEROXIDE GEL W/PUMP N Pharmacy PA  
clindamycin phos/skin clnsr 19 CLINDACIN PAC KIT N Pharmacy PA  
clindamycin phos/skin clnsr 19 CLINDACIN ETZ KIT N Pharmacy PA  
clindamycin phosphate CLINDAMYCIN PHOSPHATE GEL DAILY N Pharmacy PA  
clindamycin/benzoyl/emol cmb94 NEUAC CMB CR GEL N Pharmacy PA  
dapsone DAPSONE GEL (GRAM) N Pharmacy PA  
dapsone DAPSONE GEL W/PUMP N Pharmacy PA  
isotretinoin ISOTRETINOIN CAPSULE N Pharmacy PA  
isotretinoin ABSORICA CAPSULE N Pharmacy PA  
isotretinoin, micronized ABSORICA LD CAPSULE N Pharmacy PA  
ivermectin SOOLANTRA CREAM (G) N Pharmacy PA  
ivermectin IVERMECTIN CREAM (G) N Pharmacy PA  
metronidazole METRONIDAZOLE GEL W/PUMP N Pharmacy PA  
tazarotene TAZAROTENE FOAM N Pharmacy PA  
tazarotene FABIOR FOAM N Pharmacy PA  
tretinoin microspheres TRETINOIN MICROSPHERE GEL W/PUMP N Pharmacy PA  
tretinoin/benzoyl peroxide TWYNEO CREAM (G) N Pharmacy PA  
trifarotene AKLIEF CREAM (G) N Pharmacy PA  
benzoyl peroxide EPSOLAY CREAM (G)    
brimonidine tartrate MIRVASO GEL W/PUMP    
brimonidine tartrate BRIMONIDINE TARTRATE GEL W/PUMP    
metronidazole ROSADAN CREAM (G)    
metronidazole METRONIDAZOLE CREAM (G)    
metronidazole METROCREAM CREAM (G)    
metronidazole ROSADAN GEL (GRAM)    
metronidazole METRONIDAZOLE GEL (GRAM)    
metronidazole METROGEL GEL (GRAM)    
metronidazole METRONIDAZOLE LOTION    
metronidazole/skin cleanser 23 ROSADAN KIT CL-CRM    
metronidazole/skin cleanser 23 ROSADAN KIT CL-GEL    
oxymetazoline HCl RHOFADE CREAM (G)   May 25, 2017
salicylic acid DERMACINRX ATRIX LIQUID    
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