Emollients Protectives

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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    
ceramide 1,3,6-II/B3/hyalur ac CERAVE PM LOTION ER    
ceramides 1,3,6-II CERAVE CREAM (G)    
ceramides 1,3,6-II CERAVE LOTION    
cetyl alc/stearyl alc/pg/sls CETAPHIL CREAM (G)    
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 THERASEAL CREAM (G)    
dimethicone THERA MOISTURIZING CREAM(ML)    
dimethicone DERMACINRX SKIN REPAIR COMPLEX CREAM(ML)    
dimethicone CERAVE LOTION    
dimethicone MOISTUREL LOTION    
emollient combination no.10 LUXAMEND CREAM (G)    
emollient combination no.103 CERACADE EMULSN(G)    
emollient combination no.40 CETAPHIL LOTION    
emollient combination no.46 MEDERMA CREAM (G)    
emollient combination no.58 PEN-KERA CREAM(ML)    
emollient combination no.62 CETAPHIL RESTORADERM LOTION    
emollient combination no.65 KERADAN CREAM (G)    
gly/dimeth/petrolat,wht/water CETAPHIL CREAM (G)    
glycer/dimeth/shea/stearyl alc CETAPHIL CREAM (G)    
glycerin GLYCERIN LIQUID    
glycerin GLYCERIN SOLUTION    
glycerin/hyaluronate sodium OCEAN GEL (GRAM)    
glycerin/mineral oil EXTRA CARE SKIN LOTION LOTION    
glycerin/propylene glycol CANDERMYL CREAM (G)    
glycerin/zinc oxide/phenol liq OSTIDERM LOTION    
herbal drugs AQUA GLYCOLIC LOTION    
lactic acid LACTINOL HX CREAM (G)    
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 EXTRA CARE HAND AND BODY LOTION    
lanolin/mineral oil HAND & BODY LOTION    
lanolin/mineral oil THERA-P LOTION    
lanolin/mineral oil THERA-P HAND AND BODY LOTION LOTION    
lanolin/mineral oil BATH OIL OIL    
lanolin/mineral oil THERAPEUTIC 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)    
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 BABY SKIN PROTECTANT OINT. (G)    
petrolatum,white PETROLATUM 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-SCREEN LOTION    
titanium dioxide TI-BABY LOTION    
trolamine salicylate/aloe vera ARTHRICREAM RUB CREAM (G)    
vit E acet/gly/dimeth/water CETAPHIL 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 SKIN PROTECTANT A AND D OINT. (G)    
vitamins A and D VITAMIN A AND D OINT. (G)    
vits A and D/white pet/lanolin VITAMIN A AND D OINT. (G)    
zinc oxide Z-BUM CREAM (G)    
zinc oxide ZINC OXIDE CREAM (G)    
zinc oxide COZIMA CREAM (G)    
zinc oxide SKIN PROTECTANT CREAM(ML)    
zinc oxide DIAPER RASH OINTMENT OINT. (G)    
zinc oxide DR. SMITH'S DIAPER OINT. (G)    
zinc oxide ZINC OXIDE OINT. (G)    
zinc oxide LASSAR'S PASTE PASTE (G)    
zinc oxide ZINC OXIDE 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)