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 | New Drug Evaluation |
---|---|---|---|---|---|
ammonium lactate | AMMONIUM LACTATE | CREAM (G) | Y | ||
ammonium lactate | AMMONIUM LACTATE | CREAM (G) | Y | ||
ammonium lactate | AMMONIUM LACTATE | LOTION | Y | ||
ammonium lactate | SKIN TREATMENT | LOTION | Y | ||
ammonium lactate | AMMONIUM LACTATE | LOTION | Y | ||
ammonium lactate | AMLACTIN | 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 alcohol/stearyl alcohol | CAM | LOTION | Y | ||
colloidal oatmeal | EUCERIN BABY ECZEMA RELIEF | CREAM (G) | Y | ||
colloidal oatmeal | ECZEMA RELIEF | CREAM (G) | Y | ||
colloidal oatmeal | AVEENO MOISTURIZING CREAM | CREAM (G) | Y | ||
colloidal oatmeal | GOLD BOND MEDICATED ECZEMA RLF | CREAM (G) | Y | ||
colloidal oatmeal | AVEENO BABY | CREAM (G) | Y | ||
colloidal oatmeal | EUCERIN ECZEMA RELIEF | CREAM (G) | Y | ||
colloidal oatmeal | GOLD BOND ULTIMATE ECZEMA RLF | CREAM (G) | Y | ||
colloidal oatmeal | ECZEMA CARE | CREAM(ML) | Y | ||
colloidal oatmeal | LIPIKAR ECZEMA | 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 | 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 | SWEEN 24 | 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 | ||
gly/benzyl alc/petrolat,wht | MOISTUREL | LOTION | Y | ||
glycerin/dimeth/surfactants | ONE-STEP | LOTION | Y | ||
lactic acid/urea | AQUA LACTEN | LOTION | Y | ||
lanolin | SKIN PROTECTANT | CREAM (G) | Y | ||
lanolin | LANTISEPTIC | CREAM (G) | Y | ||
lanolin | SOOTHE & COOL MEDSEPTIC | OINT. (G) | Y | ||
lanolin | SOOTHE AND COOL MEDSEPTIC | OINT. (G) | Y | ||
lanolin | LANASHIELD | OINT. (G) | Y | ||
lanolin/mineral oil | EXTRA CARE HAND AND BODY | LOTION | Y | ||
lanolin/mineral oil | HAND & BODY | LOTION | Y | ||
lanolin/mineral oil | THERA-P | LOTION | Y | ||
lanolin/mineral oil | THERA-P HAND AND BODY LOTION | LOTION | Y | ||
lanolin/mineral oil | DERMAVANTAGE | LOTION | Y | ||
lecithin/glycerin/dimethicone | COMPLEX 15 | LOTION | Y | ||
menthol/zinc oxide | RISAMINE | OINT. (G) | Y | ||
menthol/zinc oxide | CALASOOTHE | OINT. (G) | Y | ||
menthol/zinc oxide | CALPROTECT | 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 | CALMOSEPTINE | 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 | ||
mineral oil/petrolatum,white | DERMACERIN | CREAM (G) | Y | ||
petrolatum,white | CARRINGTON MOISTURE BARRIER | CREAM (G) | Y | ||
petrolatum,white | D-CERIN | CREAM (G) | Y | ||
petrolatum,white | BABY SKIN PROTECTANT | OINT. (G) | Y | ||
petrolatum,white | PETROLATUM | OINT. (G) | Y | ||
petrolatum,white | AQUAPHOR | OINT. (G) | Y | ||
petrolatum,white | AQUAPHOR BABY HEALING | OINT. (G) | Y | ||
petrolatum,white | BALMEX | OINT. (G) | Y | ||
petrolatum,white | CERAVE BABY HEALING | OINT. (G) | Y | ||
petrolatum,white | FLANDERS HEALING OINTMENT | OINT. (G) | Y | ||
petrolatum,white | CRITIC-AID CLEAR | OINT. (G) | Y | ||
petrolatum,white | A & D BARRIER | OINT. (G) | Y | ||
petrolatum,white | DAYLOGIC ADVANCED HEALING | OINT. (G) | Y | ||
petrolatum,white | DERMAPHOR | OINT. (G) | Y | ||
petrolatum,white | DESITIN MULTI-PURPOSE | OINT. (G) | Y | ||
petrolatum,white | DRY SKIN TREATMENT | OINT. (G) | Y | ||
petrolatum,white | CERAVE HEALING | OINT. (G) | Y | ||
petrolatum,white | PROTECTIVE OINTMENT | OINT. (G) | Y | ||
petrolatum,white | WHITE PETROLATUM | OINT. (G) | Y | ||
petrolatum,white | AQUAGARD | OINT. (G) | Y | ||
petrolatum,white | REMEDY CLEAR-AID | OINT. (G) | Y | ||
petrolatum,white | ADVANCED HEALING | OINT. (G) | Y | ||
petrolatum,white | PROPHYLLIN CCC | OINT. (G) | Y | ||
petrolatum,white | HYDROPHOR | OINT. (G) | Y | ||
petrolatum,white | GOLD BOND ADVANCED HEALING | OINT. (G) | Y | ||
petrolatum,white | SKIN PROTECTANT | 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 | ||
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 | A AND D | OINT. (G) | Y | ||
vits A and D/white pet/lanolin | VITAMIN 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 | SKIN PROTECTANT 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 | BOUDREAUXS RASH KICKING | OINT. (G) | Y | ||
zinc oxide | PERISHIELD | OINT. (G) | Y | ||
zinc oxide | DIAPER RASH | OINT. (G) | Y | ||
zinc oxide | ZINC OXIDE | 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 | DIAPER RASH OINTMENT | OINT. (G) | Y | ||
zinc oxide/cod liver oil | DIAPER RELIEF | OINT. (G) | Y | ||
zinc oxide/cod liver oil | PEDIATRIC OINTMENT | 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 | PA Document | |
aloe vera extract/allantoin | COATS ALOE MOISTURIZING | LOTION | N | PA Document | |
ascorbic acid/cyclometh/dimeth | CITRADERM | CREAM (G) | N | PA Document | |
cold cream | COLD CREAM | CREAM (G) | N | PA Document | |
cold cream/zinc oxide/star/lan | DERMACLOUD | OINT. (G) | N | PA Document | |
dimethicone | THERA MOISTURIZING | CREAM (G) | N | PA Document | |
emollient combination no.46 | MEDERMA | CREAM (G) | N | PA Document | |
emollient combination no.65 | KERADAN | CREAM (G) | N | PA Document | |
lecithin/glycerin/dimethicone | COMPLEX 15 | CREAM (G) | N | PA Document | |
mineral oil/w.pet/alcohols/sls | VELVACHOL | CREAM (G) | N | PA Document | |
mineral,lanolin oils/prop glyc | BALNEOL | LOTION | N | PA Document | |
sod,ammonium,potassium lactate | AMLACTIN | CREAM (G) | N | PA Document | |
zinc oxide | Z-BUM | CREAM (G) | N | PA Document | |
zinc oxide | ZINC OXIDE | CREAM (G) | N | PA Document | |
zinc oxide | COZIMA | CREAM (G) | N | PA Document | |
zinc oxide | SKIN PROTECTANT | CREAM(ML) | N | PA Document | |
allantoin/onion/peg/water | MEDERMA | GEL (GRAM) | |||
allantoin/onion/peg/water | MEDERMA FOR KIDS | GEL (GRAM) | |||
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 | SUSPENSION | |||
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/hyaluronate sodium | OCEAN | GEL (GRAM) | |||
glycerin/mineral oil | EXTRA CARE SKIN LOTION | LOTION | |||
glycerin/zinc oxide/phenol liq | OSTIDERM | 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 | |||
mineral,lanolin oils/prop glyc | BALNEOL | LOTION PKT | |||
sod chlord/lanolin/min.oil/pet | DERMALUBE | LOTION | |||
sodium chloride/potass/cal/mag | HYDRISEA | LOTION | |||
titanium dioxide | TI-BABY | LOTION | |||
titanium dioxide | TI-SCREEN | LOTION | |||
vitamin E | VITAMIN E | CREAM (G) | |||
vitamin E | VITAMIN E | OIL | |||
vitamin E/aloe vera | ALOE E | CREAM (G) | |||
vitamins A and D | SKIN PROTECTANT A AND D | OINT. (G) | |||
vitamins A and D | VITAMIN A AND D | OINT. (G) | |||
zinc oxide | LASSAR'S PASTE | PASTE (G) | |||
zinc oxide | ZINC OXIDE | PASTE (G) | |||
zinc oxide | ZINCTRAL | PASTE (G) | |||
zinc oxide | YEAST-X | POWDER | |||
zinc oxide/cod liver oil | DIAPER RELIEF | OINT. (G) |