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 | N | ||
| ammonium lactate | AMMONIUM LACTATE | CREAM (G) | Y | N | ||
| ammonium lactate | SKIN TREATMENT | LOTION | Y | N | ||
| calamine/phenol liquid | CALAMINE PHENOLATED | LOTION | Y | N | ||
| calamine/zinc oxide | BABY ANTI MONKEY BUTT | CREAM (G) | Y | N | ||
| calamine/zinc oxide | CALAMINE | LOTION | Y | N | ||
| ceramides 1,3,6-II | CERAVE | LOTION | Y | N | ||
| cetyl alc/stearyl alc/pg/sls | CETAPHIL | CREAM (G) | Y | N | ||
| colloidal oatmeal | GOLD BOND ULTIMATE ECZEMA RLF | CREAM (G) | Y | N | ||
| colloidal oatmeal | GOLD BOND MEDICATED ECZEMA RLF | CREAM (G) | Y | N | ||
| colloidal oatmeal | ECZEMA CARE | CREAM(ML) | Y | N | ||
| dimethic/zinc ox/vits A,D/aloe | A AND D DIAPER RASH | CREAM (G) | Y | N | ||
| dimethicone | 4-N-1 | CREAM (G) | Y | N | ||
| dimethicone | PROSHIELD GLOVE | CREAM (G) | Y | N | ||
| dimethicone/colloidal oatmeal | AVEENO | LOTION | Y | N | ||
| dimethicone/zinc oxide | DYNASHIELD-DIMETHICONE | CREAM (G) | Y | N | ||
| emollient combination no.40 | CETAPHIL | LOTION | Y | N | ||
| gly/benzyl alc/petrolat,wht | MOISTUREL | LOTION | Y | N | ||
| gly/dimeth/petrolat,wht/water | CETAPHIL | CREAM (G) | Y | N | ||
| lanolin | SKIN PROTECTANT | CREAM (G) | Y | N | ||
| lanolin | SOOTHE & COOL MEDSEPTIC | OINT. (G) | Y | N | ||
| lanolin | LANASHIELD | OINT. (G) | Y | N | ||
| lanolin | SOOTHE AND COOL MEDSEPTIC | OINT. (G) | Y | N | ||
| lanolin/mineral oil | THERA-P | LOTION | Y | N | ||
| lanolin/mineral oil | EXTRA CARE HAND AND BODY | LOTION | Y | N | ||
| lanolin/mineral oil | DERMAVANTAGE | LOTION | Y | N | ||
| menthol/zinc oxide | RISAMINE | OINT. (G) | Y | N | ||
| menthol/zinc oxide | MOISTURE BARRIER OINTMENT | OINT. (G) | Y | N | ||
| menthol/zinc oxide | HYDROSEPTINE | OINT. (G) | Y | N | ||
| menthol/zinc oxide | CALMOSEPTINE | OINT. (G) | Y | N | ||
| min oil/petrolatum/castor oil | I.S.P. | LOTION | Y | N | ||
| mineral oil/i-prop myr/water | MOISTURIN | LOTION | Y | N | ||
| petrolatum,white | DERMACERIN | CREAM (G) | Y | N | ||
| petrolatum,white | D-CERIN | CREAM (G) | Y | N | ||
| petrolatum,white | CARRINGTON MOISTURE BARRIER | CREAM (G) | Y | N | ||
| petrolatum,white | PETROLATUM | OINT. (G) | Y | N | ||
| petrolatum,white | CERAVE BABY HEALING | OINT. (G) | Y | N | ||
| petrolatum,white | WHITE PETROLATUM | OINT. (G) | Y | N | ||
| petrolatum,white | REMEDY CLEAR-AID | OINT. (G) | Y | N | ||
| petrolatum,white | PROPHYLLIN CCC | OINT. (G) | Y | N | ||
| petrolatum,white | GOLD BOND ADVANCED HEALING | OINT. (G) | Y | N | ||
| petrolatum,white | DRY SKIN TREATMENT | OINT. (G) | Y | N | ||
| petrolatum,white | DERMAPHOR | OINT. (G) | Y | N | ||
| petrolatum,white | CRITIC-AID CLEAR | OINT. (G) | Y | N | ||
| petrolatum,white | AQUAPHOR | OINT. (G) | Y | N | ||
| petrolatum,white | ADVANCED HEALING | OINT. (G) | Y | N | ||
| vit A/vitamin D3/E/aloe v/zinc | PERIGUARD | OINT. (G) | Y | N | ||
| vitamin E | VITAMIN E | CREAM (G) | Y | N | ||
| vitamins A and D | VITAMIN A AND D | CREAM (G) | Y | N | ||
| vitamins A and D | SWEEN CREAM | CREAM (G) | Y | N | ||
| vits A and D/white pet/lanolin | VITAMIN A & D | OINT. (G) | Y | N | ||
| vits A and D/white pet/lanolin | A AND D | OINT. (G) | Y | N | ||
| zinc oxide | DESITIN DAILY DEFENSE | CREAM (G) | Y | N | ||
| zinc oxide | DYNASHIELD | CREAM (G) | Y | N | ||
| zinc oxide | AQUAPHOR BABY DIAPER RASH | CREAM (G) | Y | N | ||
| zinc oxide | DIAPER RASH | OINT. (G) | Y | N | ||
| zinc oxide | ZINC OXIDE | OINT. (G) | Y | N | ||
| zinc oxide | PERISHIELD | OINT. (G) | Y | N | ||
| zinc oxide | BOUDREAUXS | OINT. (G) | Y | N | ||
| zinc oxide | DIAPER RASH | OINT. (G) | Y | N | ||
| zinc oxide/cod liver oil | PEDIATRIC OINTMENT | OINT. (G) | Y | N | ||
| zinc oxide/panthenol/vitamin E | BALMEX ADULT CARE | CREAM (G) | Y | N | ||
| aloe vera extract/allantoin | COATS ALOE | CREAM (G) | N | Pharmacy PA | N | |
| aloe vera extract/allantoin | COATS ALOE MOISTURIZING | LOTION | N | Pharmacy PA | N | |
| cold cream/zinc oxide/star/lan | DERMACLOUD | OINT. (G) | N | Pharmacy PA | N | |
| dimethicone | THERA MOISTURIZING | CREAM (G) | N | Pharmacy PA | N | |
| glycerin/propylene glycol | CANDERMYL | CREAM (G) | N | Pharmacy PA | N | |
| lecithin/glycerin/dimethicone | COMPLEX 15 | CREAM (G) | N | Pharmacy PA | N | |
| sod,ammonium,potassium lactate | AMLACTIN | CREAM (G) | N | Pharmacy PA | N | |
| zinc oxide | ZINC OXIDE | CREAM (G) | N | Pharmacy PA | N | |
| zinc oxide | Z-BUM | CREAM (G) | N | Pharmacy PA | N | |
| aloe vera extract/allantoin | COATS ALOE | LIQUID | N | |||
| aloe vera/petrolatum | ALOE VESTA | OINT. (G) | N | |||
| aloe vera/soap | ALOE VESTA | LIQ. SOAP | N | |||
| benzoin | BENZOIN | TINCTURE | N | |||
| calamine/zinc oxide/phenol liq | CALAMINE-ZINC OXIDE-PHENOL | SUSPENSION | N | |||
| dextranomer | ENVISAN | KIT | N | |||
| dimethicone | DERMACINRX SKIN REPAIR COMPLEX | CREAM(ML) | N | |||
| dimethicone | THERA MOISTURIZING | CREAM(ML) | N | |||
| glycerin | GLYCERIN | SOLUTION | N | |||
| lanolin/mineral oil | THERAPEUTIC BATH OIL | OIL | N | |||
| lanolin/petrolatum,white | PHISODERM | LIQUID | N | |||
| mineral oil/petrolatum,white | DERMALINE FORMULA | LOTION | N | |||
| vitamin E | VITAMIN E | CREAM (G) | N | |||
| vitamins A and D | VITAMIN A AND D | OINT. (G) | N | |||
| zinc oxide | ZINC OXIDE | PASTE (G) | N | |||
| zinc oxide | LASSAR'S PASTE | PASTE (G) | N | |||
| zinc oxide | YEAST-X | POWDER | N | |||
| zinc oxide | BEBE BOTTOMS DIAPER RASH | SPRAY | N | |||
| zinc oxide/cod liver oil | DIAPER RELIEF | OINT. (G) | N |