Emollients Protectives
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 |
|---|---|---|---|---|---|
| allantoin/onion/peg/water | MEDERMA FOR KIDS | GEL (GRAM) | |||
| allantoin/onion/peg/water | MEDERMA | GEL (GRAM) | |||
| aloe vera extract/allantoin | COATS ALOE | CREAM (G) | |||
| aloe vera extract/allantoin | COATS ALOE | JELLY(ML) | |||
| aloe vera extract/allantoin | COATS ALOE | LIQUID | |||
| aloe vera extract/allantoin | COATS ALOE MOISTURIZING | LOTION | |||
| aloe vera/petrolatum | ALOE VESTA | OINT. (G) | |||
| aloe vera/soap | ALOE VESTA | LIQ. SOAP | |||
| ammonium lactate | AMMONIUM LACTATE | CREAM (G) | |||
| ammonium lactate | AMLACTIN | KIT | |||
| ammonium lactate | AMMONIUM LACTATE | LOTION | |||
| ascorbic acid/cyclometh/dimeth | CITRADERM | CREAM (G) | |||
| benzoin | BENZOIN | TINCTURE | |||
| calamine | CALAMINE | LOTION | |||
| calamine/phenol liquid | CALAMINE PHENOLATED | LOTION | |||
| calamine/zinc oxide | CALAMINE | LOTION | |||
| calamine/zinc oxide/phenol liq | CALAMINE | SUSPENSION | |||
| cetyl alcohol/stearyl alcohol | CAM | LOTION | |||
| cold cream | COLD CREAM | CREAM (G) | |||
| cold cream/zinc oxide/star/lan | DERMACLOUD | OINT. (G) | |||
| dextranomer | ENVISAN | KIT | |||
| dimethicone | THERA MOISTURIZING | CREAM (G) | |||
| dimethicone | DERMACINRX SKIN REPAIR COMPLEX | CREAM(ML) | |||
| dimethicone | THERA MOISTURIZING | CREAM(ML) | |||
| dimethicone | DERMACINRX DIMOPAIR | CREAM(ML) | |||
| emollient combination no.46 | MEDERMA | CREAM (G) | |||
| emollient combination no.65 | KERADAN | CREAM (G) | |||
| 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 | |||
| lactic acid/urea | AQUA LACTEN | LOTION | |||
| lanolin | SKIN PROTECTANT | CREAM (G) | |||
| lanolin | LANOLIN HYDROUS | OINT. (G) | |||
| lanolin/mineral oil | THERAPEUTIC BATH | LIQUID | |||
| lanolin/mineral oil | THERA-P HAND AND BODY LOTION | LOTION | |||
| lanolin/mineral oil | THERA-P | LOTION | |||
| lanolin/mineral oil | HAND & BODY | LOTION | |||
| lanolin/mineral oil | EXTRA CARE HAND AND BODY | LOTION | |||
| lanolin/mineral oil | THERAPEUTIC BATH OIL | OIL | |||
| lanolin/mineral oil | BATH OIL | OIL | |||
| lanolin/petrolatum,white | PHISODERM | LIQUID | |||
| lanolin/petrolatum,white | PH SKIN CLEANSER | LIQUID | |||
| lanolin/zinc oxide | D.R.C. PERI-RECTAL | CREAM (G) | |||
| lecithin/glycerin/dimethicone | COMPLEX 15 | CREAM (G) | |||
| lecithin/glycerin/dimethicone | COMPLEX 15 | LOTION | |||
| menthol/zinc oxide | RISAMINE | OINT. (G) | |||
| mineral oil | MAPO | OIL | |||
| mineral oil/i-prop myr/water | MOISTURIN | LOTION | |||
| mineral oil/petrolatum,white | DERMALINE FORMULA | CREAM (G) | |||
| mineral oil/petrolatum,white | DERMALINE FORMULA | LOTION | |||
| mineral oil/w.pet/alcohols/sls | VELVACHOL | CREAM (G) | |||
| mineral,lanolin oils/prop glyc | BALNEOL | LOTION | |||
| mineral,lanolin oils/prop glyc | BALNEOL | LOTION PKT | |||
| petrolatum,white | PETROLATUM | OINT. (G) | |||
| petrolatum,white | BABY SKIN PROTECTANT | OINT. (G) | |||
| sod chlord/lanolin/min.oil/pet | DERMALUBE | LOTION | |||
| sod,ammonium,potassium lactate | AMLACTIN | CREAM (G) | |||
| 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 | VITAMIN A AND D | CREAM (G) | |||
| vitamins A and D | VITAMIN A AND D | OINT. (G) | |||
| vitamins A and D | SKIN PROTECTANT A AND D | OINT. (G) | |||
| vits A and D/white pet/lanolin | VITAMIN A AND D | OINT. (G) | |||
| zinc oxide | ZINC OXIDE | CREAM (G) | |||
| zinc oxide | Z-BUM | CREAM (G) | |||
| zinc oxide | COZIMA | CREAM (G) | |||
| zinc oxide | SKIN PROTECTANT | CREAM(ML) | |||
| zinc oxide | ZINC OXIDE | OINT. (G) | |||
| zinc oxide | DR. SMITH'S DIAPER | OINT. (G) | |||
| zinc oxide | DIAPER RASH | OINT. (G) | |||
| zinc oxide | ZINCTRAL | PASTE (G) | |||
| zinc oxide | ZINC OXIDE | PASTE (G) | |||
| zinc oxide | LASSAR'S PASTE | PASTE (G) | |||
| zinc oxide | YEAST-X | POWDER | |||
| zinc oxide | DR. SMITH'S ADULT BARRIER | SPRAY | |||
| zinc oxide | DR. SMITH'S DIAPER RASH | SPRAY | |||
| zinc oxide/cod liver oil | DIAPER RELIEF | OINT. (G) |