Moisturizers, Topical
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 |
|---|---|---|---|---|---|---|
| ammonium lactate | AMMONIUM LACTATE | CREAM (G) | Y | |||
| ammonium lactate | AMMONIUM LACTATE | CREAM (G) | Y | |||
| ammonium lactate | AMLACTIN | LOTION | Y | |||
| ammonium lactate | SKIN TREATMENT | LOTION | Y | |||
| ammonium lactate | AMMONIUM LACTATE | LOTION | Y | |||
| ammonium lactate | AMMONIUM LACTATE | LOTION | Y | |||
| calamine/phenol liquid | CALAMINE PHENOLATED | LOTION | Y | |||
| calamine/phenol liquid | CALAMINE PHENOLATED | LOTION | Y | |||
| calamine/zinc oxide | BABY ANTI MONKEY BUTT | CREAM (G) | Y | |||
| calamine/zinc oxide | CALAMINE | LOTION | Y | |||
| calamine/zinc oxide | CALAMINE | LOTION | Y | |||
| ceramides 1,3,6-II | CERAVE | LOTION | Y | |||
| cetyl alc/stearyl alc/pg/sls | CETAPHIL | CREAM (G) | Y | |||
| colloidal oatmeal | GOLD BOND ULTIMATE ECZEMA RLF | CREAM (G) | Y | |||
| colloidal oatmeal | GOLD BOND MEDICATED ECZEMA RLF | CREAM (G) | Y | |||
| colloidal oatmeal | EUCERIN ECZEMA RELIEF | CREAM (G) | Y | |||
| colloidal oatmeal | ECZEMA RELIEF | CREAM (G) | Y | |||
| colloidal oatmeal | CERAVE BABY ECZEMA RELIEF | CREAM (G) | Y | |||
| colloidal oatmeal | AVEENO MOISTURIZING CREAM | CREAM (G) | Y | |||
| colloidal oatmeal | EUCERIN BABY ECZEMA RELIEF | CREAM (G) | Y | |||
| colloidal oatmeal | AVEENO ECZEMA NIGHT ITCH RLF | CREAM (G) | Y | |||
| colloidal oatmeal | AVEENO BABY | CREAM (G) | Y | |||
| colloidal oatmeal | ECZEMA CARE | CREAM(ML) | Y | |||
| colloidal oatmeal | LIPIKAR ECZEMA | CREAM(ML) | Y | |||
| colloidal oatmeal | ITCH-ECZEMA RELIEF | CREAM(ML) | Y | |||
| colloidal oatmeal | ADVANCED ECZEMA CARE | CREAM(ML) | Y | |||
| colloidal oatmeal | GOLD BOND MEDICATED ECZEMA RLF | LOTION | Y | |||
| dimethic/zinc ox/vits A,D/aloe | DIAPER CREAM | CREAM (G) | Y | |||
| dimethic/zinc ox/vits A,D/aloe | A AND D DIAPER RASH | CREAM (G) | Y | |||
| dimethicone | SWEEN 24 | CREAM (G) | Y | |||
| dimethicone | PROSHIELD GLOVE | CREAM (G) | Y | |||
| dimethicone | NORMLSHIELD | CREAM (G) | Y | |||
| dimethicone | NEUTRAPHOR | CREAM (G) | Y | |||
| dimethicone | COOL BOTTOMS | CREAM (G) | Y | |||
| dimethicone | 4-N-1 | CREAM (G) | Y | |||
| dimethicone/colloidal oatmeal | AVEENO | LOTION | Y | |||
| dimethicone/colloidal oatmeal | AVEENO DAILY MOISTURIZING | LOTION | Y | |||
| dimethicone/zinc oxide | DYNASHIELD-DIMETHICONE | CREAM (G) | Y | |||
| emollient combination no.116 | GOLD BOND ULTIMATE DIABETIC | LOTION | Y | |||
| emollient combination no.40 | CETAPHIL | LOTION | Y | |||
| gly/benzyl alc/petrolat,wht | MOISTUREL | LOTION | Y | |||
| gly/dimeth/petrolat,wht/water | CETAPHIL | CREAM (G) | Y | |||
| glycerin/dimeth/surfactants | ONE-STEP | LOTION | Y | |||
| lactic acid/urea | AQUA LACTEN | LOTION | Y | |||
| lanolin | LANTISEPTIC | CREAM (G) | Y | |||
| lanolin | SKIN PROTECTANT | CREAM (G) | Y | |||
| lanolin | SOOTHE AND COOL MEDSEPTIC | OINT. (G) | Y | |||
| lanolin | SOOTHE & COOL MEDSEPTIC | OINT. (G) | Y | |||
| lanolin | LANASHIELD | OINT. (G) | Y | |||
| lanolin/mineral oil | DERMAVANTAGE | LOTION | Y | |||
| lanolin/mineral oil | THERA-P | LOTION | Y | |||
| lanolin/mineral oil | THERA-P HAND AND BODY LOTION | LOTION | Y | |||
| lanolin/mineral oil | EXTRA CARE HAND AND BODY | LOTION | Y | |||
| lanolin/mineral oil | HAND & BODY | LOTION | Y | |||
| lecithin/glycerin/dimethicone | COMPLEX 15 | LOTION | Y | |||
| menthol/zinc oxide | CALMOSEPTINE | OINT. (G) | Y | |||
| menthol/zinc oxide | MENTHOL-ZINC OXIDE | OINT. (G) | Y | |||
| menthol/zinc oxide | MOISTURE BARRIER OINTMENT | OINT. (G) | Y | |||
| menthol/zinc oxide | HYDROSEPTINE | OINT. (G) | Y | |||
| menthol/zinc oxide | CALPROTECT | OINT. (G) | Y | |||
| menthol/zinc oxide | CALASOOTHE | OINT. (G) | Y | |||
| menthol/zinc/aloe/chamomil oil | CHAMOSYN | OINT. (G) | Y | |||
| min oil/petrolatum/castor oil | I.S.P. | LOTION | Y | |||
| mineral oil/i-prop myr/water | MOISTURIN | LOTION | Y | |||
| mineral oil/petrolatum,white | DERMALINE FORMULA | CREAM (G) | Y | |||
| petrolatum,white | D-CERIN | CREAM (G) | Y | |||
| petrolatum,white | CARRINGTON MOISTURE BARRIER | CREAM (G) | Y | |||
| petrolatum,white | DERMACERIN | CREAM (G) | Y | |||
| petrolatum,white | AQUAPHOR BABY HEALING | OINT. (G) | Y | |||
| petrolatum,white | A & D BARRIER | OINT. (G) | Y | |||
| petrolatum,white | ADVANCED HEALING | OINT. (G) | Y | |||
| petrolatum,white | AQUAGARD | OINT. (G) | Y | |||
| petrolatum,white | AQUAPHOR | OINT. (G) | Y | |||
| petrolatum,white | AQUASOOTHE | OINT. (G) | Y | |||
| petrolatum,white | BABY SKIN PROTECTANT | OINT. (G) | Y | |||
| petrolatum,white | PETROLATUM | OINT. (G) | Y | |||
| petrolatum,white | CRITIC-AID CLEAR | OINT. (G) | Y | |||
| petrolatum,white | BALMEX | OINT. (G) | Y | |||
| petrolatum,white | PROPHYLLIN CCC | OINT. (G) | Y | |||
| petrolatum,white | WHITE PETROLATUM | OINT. (G) | Y | |||
| petrolatum,white | SKIN PROTECTANT | OINT. (G) | Y | |||
| petrolatum,white | PROTECTIVE OINTMENT | OINT. (G) | Y | |||
| petrolatum,white | DESITIN MULTI-PURPOSE | OINT. (G) | Y | |||
| petrolatum,white | HYDROPHOR | OINT. (G) | Y | |||
| petrolatum,white | GOLD BOND ADVANCED HEALING | OINT. (G) | Y | |||
| petrolatum,white | FLANDERS HEALING OINTMENT | OINT. (G) | Y | |||
| petrolatum,white | DRY SKIN TREATMENT | OINT. (G) | Y | |||
| petrolatum,white | DERMAPHOR | OINT. (G) | Y | |||
| petrolatum,white | DAYLOGIC ADVANCED HEALING | OINT. (G) | Y | |||
| petrolatum,white | CERAVE HEALING | OINT. (G) | Y | |||
| petrolatum,white | CERAVE BABY HEALING | OINT. (G) | Y | |||
| petrolatum,white | REMEDY CLEAR-AID | OINT. (G) | Y | |||
| petrolatum/vits A,C,E/aloe xt | GOLD BOND ULTIMATE | OINT.(ML) | Y | |||
| vit A/vitamin D3/E/aloe v/zinc | PERIGUARD | OINT. (G) | Y | |||
| vit E acet/gly/dimeth/water | CETAPHIL | LOTION | Y | |||
| vitamin E | VITAMIN E | CREAM (G) | Y | |||
| vitamin E | VITAMIN E | CREAM (G) | Y | |||
| vitamin E/vitamins A and D | VITAMIN E WITH VIT A&D | CREAM (G) | Y | |||
| vitamins A and D | VITAMIN A AND D | CREAM (G) | Y | |||
| vitamins A and D | SWEEN CREAM W/VITAMIN A & D | CREAM (G) | Y | |||
| vitamins A and D | SWEEN CREAM | CREAM (G) | Y | |||
| vits A and D/white pet/lanolin | VITAMIN A AND D | OINT. (G) | Y | |||
| vits A and D/white pet/lanolin | SKIN PROTECTANT A AND D | OINT. (G) | Y | |||
| vits A and D/white pet/lanolin | A AND D | OINT. (G) | Y | |||
| vits A and D/white pet/lanolin | VITAMIN A & D | OINT. (G) | Y | |||
| vits A and D/white pet/lanolin | VITAMIN A AND D | OINT. (G) | Y | |||
| zinc oxide | DYNASHIELD | CREAM (G) | Y | |||
| zinc oxide | DESITIN DAILY DEFENSE | CREAM (G) | Y | |||
| zinc oxide | AQUAPHOR BABY DIAPER RASH | CREAM (G) | Y | |||
| zinc oxide | DIAPER RASH | CREAM (G) | Y | |||
| zinc oxide | DIAPER RASH | OINT. (G) | Y | |||
| zinc oxide | DR. SMITH'S DIAPER | OINT. (G) | Y | |||
| zinc oxide | ZINC OXIDE | OINT. (G) | Y | |||
| zinc oxide | ENDIT | OINT. (G) | Y | |||
| zinc oxide | ZINC OXIDE | OINT. (G) | Y | |||
| zinc oxide | PERISHIELD | OINT. (G) | Y | |||
| zinc oxide | DIAPER RASH OINTMENT | OINT. (G) | Y | |||
| zinc oxide | DIAPER RASH | OINT. (G) | Y | |||
| zinc oxide | BOUDREAUXS RASH KICKING | OINT. (G) | Y | |||
| zinc oxide | BOUDREAUXS | OINT. (G) | Y | |||
| zinc oxide | AQUAPHOR BABY DIAPER RASH | OINT. (G) | Y | |||
| zinc oxide | TRIPLE PASTE | OINT. (G) | Y | |||
| zinc oxide/cod liver oil | DIAPER RELIEF | OINT. (G) | Y | |||
| zinc oxide/menthol/calamine | LANTISEPTIC | OINT. (G) | Y | |||
| zinc oxide/panthenol/vitamin E | BALMEX COMPLETE PROTECTION | CREAM (G) | Y | |||
| zinc oxide/panthenol/vitamin E | BALMEX ADULT CARE | CREAM (G) | Y | |||
| aloe vera extract/allantoin | COATS ALOE | CREAM (G) | N | Pharmacy PA | ||
| aloe vera extract/allantoin | COATS ALOE MOISTURIZING | LOTION | N | Pharmacy PA | ||
| calamine/zinc oxide | THERA CALAZINC | CREAM(ML) | N | Pharmacy PA | ||
| cold cream | COLD CREAM | CREAM (G) | N | Pharmacy PA | ||
| cold cream/zinc oxide/star/lan | DERMACLOUD | OINT. (G) | N | Pharmacy PA | ||
| dimethicone | THERA MOISTURIZING | CREAM (G) | N | Pharmacy PA | ||
| dimethicone/allantoin | DERMACINRX EXEMAX | CREAM (G) | N | Pharmacy PA | ||
| emollient combination no.65 | KERADAN | CREAM (G) | N | Pharmacy PA | ||
| glycerin/propylene glycol | CANDERMYL | CREAM (G) | N | Pharmacy PA | ||
| lecithin/glycerin/dimethicone | COMPLEX 15 | CREAM (G) | N | Pharmacy PA | ||
| sod,ammonium,potassium lactate | AMLACTIN | CREAM (G) | N | Pharmacy PA | ||
| zinc oxide | COZIMA | CREAM (G) | N | Pharmacy PA | ||
| zinc oxide | ZINC OXIDE | CREAM (G) | N | Pharmacy PA | ||
| zinc oxide | Z-BUM | CREAM (G) | N | Pharmacy PA | ||
| zinc oxide | SKIN PROTECTANT | CREAM(ML) | N | Pharmacy PA | ||
| aloe vera extract/allantoin | COATS ALOE | JELLY(ML) | ||||
| aloe vera extract/allantoin | COATS ALOE | LIQUID | ||||
| aloe vera/petrolatum | ALOE VESTA | OINT. (G) | ||||
| aloe vera/soap | ALOE VESTA | LIQ. SOAP | ||||
| ammonium lactate | AMLACTIN | KIT | ||||
| benzoin | BENZOIN | TINCTURE | ||||
| calamine | CALAMINE | LOTION | ||||
| calamine/zinc oxide | CALAMINE | LOTION | ||||
| calamine/zinc oxide/phenol liq | CALAMINE-ZINC OXIDE-PHENOL | SUSPENSION | ||||
| colloidal oatmeal | CETAPHIL ECZEMA RESTORADERM | LOTION | ||||
| dextranomer | ENVISAN | KIT | ||||
| dimethicone | DERMACINRX DIMOPAIR | CREAM(ML) | ||||
| dimethicone | DERMACINRX SKIN REPAIR COMPLEX | CREAM(ML) | ||||
| dimethicone | THERA MOISTURIZING | CREAM(ML) | ||||
| glycerin | GLYCERIN | LIQUID | ||||
| glycerin | GLYCERIN | SOLUTION | ||||
| glycerin/mineral oil | EXTRA CARE SKIN LOTION | LOTION | ||||
| herbal drugs | AQUA GLYCOLIC | LOTION | ||||
| lanolin | LANOLIN HYDROUS | OINT. (G) | ||||
| lanolin/mineral oil | THERAPEUTIC BATH | LIQUID | ||||
| lanolin/mineral oil | THERAPEUTIC BATH OIL | OIL | ||||
| lanolin/mineral oil | BATH OIL | OIL | ||||
| lanolin/petrolatum,white | PH SKIN CLEANSER | LIQUID | ||||
| lanolin/petrolatum,white | PHISODERM | LIQUID | ||||
| lanolin/zinc oxide | D.R.C. PERI-RECTAL | CREAM (G) | ||||
| mineral oil | MAPO | OIL | ||||
| mineral oil/petrolatum,white | DERMALINE FORMULA | LOTION | ||||
| sod chlord/lanolin/min.oil/pet | DERMALUBE | LOTION | ||||
| vitamin E | VITAMIN E | CREAM (G) | ||||
| vitamin E | VITAMIN E | OIL | ||||
| vitamin E/aloe vera | ALOE E | CREAM (G) | ||||
| vitamins A and D | VITAMIN A AND D | OINT. (G) | ||||
| zinc oxide | LASSAR'S PASTE | PASTE (G) | ||||
| zinc oxide | ZINCTRAL | PASTE (G) | ||||
| zinc oxide | ZINC OXIDE | PASTE (G) | ||||
| zinc oxide | YEAST-X | POWDER | ||||
| zinc oxide | BEBE BOTTOMS DIAPER RASH | SPRAY | ||||
| zinc oxide/cod liver oil | DIAPER RELIEF | OINT. (G) |