Sulfonamides
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 |
|---|---|---|---|---|---|---|
| sulfacetamide sodium/sulfur | SULFACETAMIDE SODIUM-SULFUR | CLEANSER | N | N | ||
| sulfacetamide sodium/sulfur | ZMA CLEAR | SUSPENSION | N | N | ||
| sulfacetamide sodium/sulfur | SODIUM SULFACETAMIDE-SULFUR | SUSPENSION | N | N | ||
| mafenide acetate | SULFAMYLON | CREAM (G) | N | |||
| mafenide acetate | MAFENIDE ACETATE | PACKET | N | |||
| silver sulfadiazine | SILVADENE | CREAM (G) | N | |||
| silver sulfadiazine | SILVER SULFADIAZINE | CREAM (G) | N | |||
| silver sulfadiazine | SSD | CREAM (G) | N | |||
| sulfacetamide sod/sulfur/urea | CLEANSING WASH | CLEANSER | N | |||
| sulfacetamide sodium/sulfur | SUMADAN | CLEANSER | N | |||
| sulfacetamide sodium/sulfur | SUMAXIN | CLEANSER | N | |||
| sulfacetamide sodium/sulfur | AVAR | CLEANSER | N | |||
| sulfacetamide sodium/sulfur | AVAR LS | CLEANSER | N | |||
| sulfacetamide sodium/sulfur | BP 10-1 | CLEANSER | N | |||
| sulfacetamide sodium/sulfur | SODIUM SULFACETAMIDE-SULFUR | CLEANSER | N | |||
| sulfacetamide sodium/sulfur | SSS 10-5 | CREAM (G) | N | |||
| sulfacetamide sodium/sulfur | AVAR-E | CREAM (G) | N | |||
| sulfacetamide sodium/sulfur | AVAR-E LS | CREAM (G) | N | |||
| sulfacetamide sodium/sulfur | AVAR-E GREEN | CREAM (G) | N | |||
| sulfacetamide sodium/sulfur | SODIUM SULFACETAMIDE-SULFUR | CREAM (G) | N | |||
| sulfacetamide sodium/sulfur | SSS 10-5 | FOAM | N | |||
| sulfacetamide sodium/sulfur | AVAR LS | FOAM | N | |||
| sulfacetamide sodium/sulfur | SODIUM SULFACETAMIDE-SULFUR | LOTION | N | |||
| sulfacetamide sodium/sulfur | SUMAXIN | MED. PAD | N | |||
| sulfacetamide sodium/sulfur | SULFACETAMIDE SODIUM-SULFUR | MED. PAD | N | |||
| sulfacetamide sodium/sulfur | AVAR | MED. PAD | N | |||
| sulfacetamide sodium/sulfur | AVAR LS | MED. PAD | N | |||
| sulfacetamide sodium/sulfur | SODIUM SULFACETAMIDE-SULFUR | MED. PAD | N | |||
| sulfacetamide sodium/sulfur | SUMAXIN TS | SUSPENSION | N | |||
| sulfacetamide sodium/sulfur | SODIUM SULFACETAMIDE-SULFUR | SUSPENSION | N | |||
| sulfacetamide/sulfur/cleansr23 | SUMAXIN CP | KIT | N | |||
| sulfacetamide/sulfur/cleansr23 | SUMADAN | KIT | N | |||
| sulfact sod/sulur/avob/otn/oct | SUMADAN XLT | CMB CLN CR | N | |||
| sulfadiazine | SULFADIAZINE | TABLET | N | |||
| sulfamethoxazole/trimethoprim | SULFAMETHOXAZOLE-TRIMETHOPRIM | ORAL SUSP | N | |||
| sulfamethoxazole/trimethoprim | SULFATRIM | ORAL SUSP | N | |||
| sulfamethoxazole/trimethoprim | BACTRIM | TABLET | N | |||
| sulfamethoxazole/trimethoprim | SULFAMETHOXAZOLE-TRIMETHOPRIM | TABLET | N | |||
| sulfamethoxazole/trimethoprim | BACTRIM DS | TABLET | N | |||
| sulfamethoxazole/trimethoprim | SEPTRA I.V. | VIAL | N | |||
| sulfamethoxazole/trimethoprim | BACTRIM IV | VIAL | N | |||
| sulfamethoxazole/trimethoprim | SULFAMETHOXAZOLE-TRIMETHOPRIM | VIAL | N |