Actinic Keratosis
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 |
|---|---|---|---|---|---|---|
| fluorouracil | FLUOROURACIL | CREAM (G) | Y | N | ||
| imiquimod | IMIQUIMOD | CREAM PACK | Y | N | ||
| aminolevulinic acid HCl | AMELUZ | GEL (GRAM) | N | Pharmacy PA | N | May 25, 2017 |
| diclofenac sodium | DICLOFENAC SODIUM | GEL (GRAM) | N | Pharmacy PA | N | |
| imiquimod | IMIQUIMOD | CREAM PACK | N | Pharmacy PA | N |