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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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
benzoyl peroxide micronized BENZEPRO TOWELETTE Y   N  
clascoterone WINLEVI CREAM (G) N   N  
ivermectin IVERMECTIN CREAM (G) N   N  
methoxsalen METHOXSALEN CAP LQ RAP N   N  
afamelanotide acetate SCENESSE IMPLANT   N  
avobenzone/octocrylene CETAPHIL LOTION   N  
brimonidine tartrate MIRVASO GEL W/PUMP   N  
camph/la/mo/phe/petrolat/paraf BLISTER-AID OINT. (G)   N  
camphor/alcohol ANTISEPTIC SKIN CLEANSER LIQUID   N  
camphor/phenol/petrolatum MEDICATED LIP OINT. (G)   N  
capsaicin/menthol MEDROX ADH. PATCH   N  
capsaicin/menthol DERMACINRX DIABECIN CS CREAM (G)   N  
capsicum oleoresin DERMACINRX CIRCATA CREAM (G)   N  
capsicum oleoresin CAPSAICIN-CAPSICUM OLEORESIN CREAM (G)   N  
capsicum oleoresin DERMACINRX PENETRAL CREAM(ML)   N  
diphenhydramine HCl ANTI-ITCH SPRAY   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL SPRAY   N  
diphenhydramine HCl/zinc acet ANTI-ITCH CREAM (G)   N  
diphenhydramine HCl/zinc acet BANOPHEN ANTI-ITCH CREAM (G)   N  
diphenhydramine HCl/zinc acet ITCH RELIEF SPRAY   N  
doxepin HCl DOXEPIN HCL CREAM (G)   N  
doxepin HCl ZONALON CREAM (G)   N  
eucalyptus oil/menthol/camphor CHEST RUB OINT. (G)   N  
fluocinolone/tretinoin/h-quin TRI-LUMA CREAM (G)   N  
glycerin/witch hazel leaf FLEET MEDICATED WIPES MED. PAD   N  
glycerin/witch hazel leaf ANTISEPTIC CLEANSING PADS MED. PAD   N  
glycerin/witch hazel leaf PERIES 40 PADS MED. PAD   N  
hydrophilic cream HYDROPHILIC OINT. (G)   N  
ichthammol ICHTHAMMOL OINT. (G)   N  
menthol PAIN RELIEF PATCH ADH. PATCH   N  
menthol COLD-HOT EXTRA STRENGTH ADH. PATCH   N  
menthol THERAPEUTIC BLUE GEL GEL (GRAM)   N  
menthol COOLING PAIN RELIEF GEL (ML)   N  
menthol/camphor CAMPHOR-MENTHOL GEL W/APPL   N  
menthol/camphor CAMPHOTROL GEL W/APPL   N  
methyl salicylate METHYL SALICYLATE CREAM (G)   N  
methyl salicylate METHYLTEN CREAM (G)   N  
methyl salicylate/menth/camph PAIN RELIEVING PATCH ADH. PATCH   N  
methyl salicylate/menth/camph MENTICAM GEL (GRAM)   N  
methyl salicylate/menthol MUSCLE RUB CREAM (G)   N  
methyl salicylate/menthol ULTRA STRENGTH MUSCLE RUB CREAM (G)   N  
methyl salicylate/menthol ARTHRICREAM HEAT CREAM (G)   N  
methyl salicylate/menthol MENCYLATE CREAM(ML)   N  
methyl salicylate/menthol MUSCLE RUB OINT. (G)   N  
methyl salicylate/menthol MENTHODERM OINT. (G)   N  
methyl salicylate/menthol BACK RUB OINT. (G)   N  
metronidazole METRONIDAZOLE CREAM (G)   N  
metronidazole ROSADAN CREAM (G)   N  
metronidazole METRONIDAZOLE GEL (GRAM)   N  
metronidazole METROGEL GEL (GRAM)   N  
metronidazole METRONIDAZOLE LOTION   N  
metronidazole/skin cleanser 23 ROSADAN KIT CL-CRM   N  
minoxidil MINOXIDIL FOR WOMEN FOAM   N  
minoxidil GAINEXTRA HAIR REGROWTH SOLUTION   N  
oxybenzone/padimate O SUNBLOCK LOTION   N  
podofilox PODOFILOX GEL (GRAM)   N  
podofilox CONDYLOX GEL (GRAM)   N  
podofilox PODOFILOX SOLUTION   N  
pramoxine HCl/ammonium lactate AMLACTIN KIT   N  
pramoxine HCl/calamine CALDYPHEN LOTION   N  
pramoxine HCl/calamine CALAMINE PLUS LOTION   N  
pramoxine HCl/camph/zinc acet CLEAR MEDICATED LOTION LOTION   N  
pramoxine HCl/zinc acetate CALDYPHEN CLEAR LOTION   N  
pramoxine/zinc oxide/calamine DERMAGESIC CREAM (G)   N  
pyrithione zinc SHAMPOO PLUS SHAMPOO   N  
salicylic acid MEDICATED WART REMOVER ADH. PATCH   N  
salicylic acid CALLUS REMOVERS ADH. PATCH   N  
salicylic acid DERMACINRX ATRIX CLEANSER   N  
salicylic acid SALYCIM CREAM (G)   N  
salicylic acid RAYASAL CREAM (G)   N  
salicylic acid DERMACINRX ATRIX CREAM(ML)   N  
salicylic acid SALICYLIC ACID FOAM   N  
salicylic acid CLEARACYLIC PRO GEL (GRAM)   N  
salicylic acid SALICYLIC ACID LIQ-FILM   N  
salicylic acid LIQUID CORN-CALLUS REMOVER LIQUID   N  
salicylic acid WART LIQUID LIQUID   N  
salicylic acid WART REMOVER LIQUID   N  
salicylic acid THERAPEUTIC DANDRUFF SHAMPOO SHAMPOO   N  
salicylic acid/coal tar/sulfur SEBEX-T SHAMPOO   N  
selenium sulfide SELSUN GOLD FOR WOMEN SHAMPOO   N  
selenium sulfide SELENIUM SULFIDE SHAMPOO   N  
selenium sulfide ANTI-DANDRUFF SHAMPOO   N  
skin cleanser SEPTI-SOFT CLEANSER   N  
skin cleanser CETAPHIL CLEANSER   N  
skin cleanser comb no.19 ACUWASH CLEANSER   N  
skin cleanser comb no.42 CETAPHIL GENTLE SKIN CLEANSER CLEANSER   N  
skin cleanser comb.no.23 REHYLA CLEANSER   N  
soap SENSI-CARE LIQ. SOAP   N  
sulfacetamide sodium OVACE PLUS CLEANSER   N  
sulfacetamide sodium SODIUM SULFACETAMIDE CLNSR GEL   N  
sulfacetamide sodium OVACE PLUS WASH CLNSR GEL   N  
sulfacetamide sodium OVACE PLUS LOTION   N  
thrombin/fibrinog/aprotin/calc ARTISS SYRINGE   N  
thrombin/fibrinog/aprotin/calc TISSEEL VHSD SYRINGE   N  
trolamine salicylate ARTHRITIS CREAM (G)   N  
trolamine salicylate ARTHRICREAM CREAM (G)   N  
trolamine salicylate PAIN RELIEVING CREAM (G)   N  
urea UREA CREAM (G)   N  
urea DERMACURE CREAM (G)   N  
urea/camphor/menthol/eucalyptl TOETAL FRESH SOLUTION   N  
witch hazel leaf WITCH DOCTOR PAD   N  
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