All Other Dermatologicals

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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
benzoyl peroxide micronized BENZEPRO TOWELETTE Y    
clascoterone WINLEVI CREAM (G) N    
ivermectin IVERMECTIN CREAM (G) N    
ivermectin SOOLANTRA CREAM (G) N    
methoxsalen METHOXSALEN CAP LQ RAP N    
metronidazole METRONIDAZOLE GEL W/PUMP N    
acitretin ACITRETIN CAPSULE    
afamelanotide acetate SCENESSE IMPLANT    
alcohol/propylene glycol AQUAMED LOTION    
aluminum chloride XERAC AC SOLUTION    
aluminum oxide/hexachlorophene BRASIVOL CLEANSER    
avobenzone/octocryl/octyl sal CETAPHIL DERMACONTROL LOTION    
avobenzone/octocrylene CETAPHIL LOTION    
benzophenone/octinox/Dihd-Acet TI-SCREEN CREAM(ML)    
benzoyl perox/skin clnsr/emoll ACNEFREE SEVERE KIT    
benzoyl peroxide/skin clnsr 24 ACNEFREE COMBO. PKG    
bimatoprost LATISSE DROP W/APP    
bimatoprost BIMATOPROST DROP W/APP    
brimonidine tartrate MIRVASO GEL W/PUMP    
calcium acetate/aluminum sulf ASTRINGENT SOLUTION POWD PACK    
camph/la/mo/phe/petrolat/paraf BLISTER-AID OINT. (G)    
camphor CAMPHOR SPIRIT    
camphor/alcohol ANTISEPTIC SKIN CLEANSER LIQUID    
camphor/phenol CAMPHO-PHENIQUE SOLUTION    
camphor/phenol INSTANT PAIN RELIEF SOLUTION    
camphor/phenol/petrolatum MEDICATED LIP OINT. (G)    
capsicum oleoresin DERMACINRX CIRCATA CREAM (G)    
capsicum oleoresin DERMACINRX CIRCATRIX CREAM (G)    
capsicum oleoresin DERMACINRX PENETRAL CREAM(ML)    
capsicum oleoresin/turp oil SLOANS LINIMENT    
ceramides 1,3,6-II CERAVE CLEANSER    
ceramides 1,3,6-II/niacinamide CERAVE FOAMING FACIAL CLEANSER    
chlorcyclizine HCl/hydrocort MANTADIL CREAM (G)    
chlorhexidine/glycerin/he-cell LUBRICATING JELLY JELLY (G)    
chlorhexidine/glycerin/he-cell MAXILUBE JELLY (G)    
diphenhydramine HCl ALLERGY CREAM CREAM (G)    
diphenhydramine HCl DIPHENHYDRAMINE HCL CREAM (G)    
diphenhydramine HCl ANTI-ITCH GEL (ML)    
diphenhydramine HCl ANTI-ITCH SPRAY    
diphenhydramine HCl DIPHENHYDRAMINE HCL SPRAY    
diphenhydramine HCl/calamine CALDYPHEN LOTION    
diphenhydramine HCl/zinc acet ANTI-ITCH CREAM (G)    
diphenhydramine HCl/zinc acet ITCH RELIEF CREAM (G)    
diphenhydramine HCl/zinc acet BANOPHEN ANTI-ITCH CREAM (G)    
diphenhydramine HCl/zinc acet ITCH RELIEF SPRAY    
doxepin HCl DOXEPIN HCL CREAM (G)    
doxepin HCl PRUDOXIN CREAM (G)    
doxepin HCl ZONALON CREAM (G)    
edetate disodium/peg EYESCRUB PAD    
eflornithine HCl VANIQA CREAM (G)    
eucalypt/men/camph/turp/wh.pet MEDICATED CHEST RUB OINT. (G)    
eucalyptus oil/menthol/camphor CHEST RUB OINT. (G)    
fluocinolone/tretinoin/h-quin TRI-LUMA CREAM (G)    
glycerin AQUA GLYCOLIC SHAMPOO    
glycerin/witch hazel leaf ANTISEPTIC CLEANSING PADS MED. PAD    
glycerin/witch hazel leaf FLEET MEDICATED WIPES MED. PAD    
glycerin/witch hazel leaf HYGIENIC CLEANSING PADS MED. PAD    
glycerin/witch hazel leaf PERIES 40 PADS MED. PAD    
glycopyrronium tosylate QBREXZA TOWELETTE    
green soap GREEN SOAP TINCTURE    
hydrophilic cream HYDROPHILIC OINT. (G)    
hydroquinone ESOTERICA FADE CREAM CREAM (G)    
hydroquinone HYDROQUINONE CREAM (G)    
hydroquinone/oxybenzone/padima ESOTERICA FADE CREAM CREAM (G)    
ichthammol ICHTHAMMOL OINT. (G)    
imiquimod ZYCLARA CREAM PACK    
imiquimod IMIQUIMOD CREAM PACK    
imiquimod IMIQUIMOD CRM MD PMP    
imiquimod ZYCLARA CRM MD PMP    
m-salicy/aloe/menthol/eucalypt COATS ALOE ANALGESIC LINIMENT    
menthol COLD-HOT EXTRA STRENGTH ADH. PATCH    
menthol MENTHOL COLD AND HOT ADH. PATCH    
menthol COLD-HOT PAIN RELIEF ADH. PATCH    
menthol BLUE GEL GEL (GRAM)    
menthol THERAPEUTIC BLUE GEL GEL (GRAM)    
menthol WONDER ICE GEL (GRAM)    
menthol REFLEX PAIN RELIEF GEL (GRAM)    
menthol PAIN RELIEVING GEL GEL (GRAM)    
menthol PAIN RELIEF GEL (GRAM)    
menthol ICE BLUE GEL GEL (GRAM)    
menthol DOLOXYL GEL (GRAM)    
menthol COLD THERAPY SPRAY    
menthol/camphor CAMPHOTROL GEL W/APPL    
menthol/camphor CAMPHOTREX GEL W/APPL    
menthol/camphor ANTI-ITCH LOTION    
menthol/camphor/phenol MEDICATED SKIN CREAM CREAM (G)    
menthol/zinc oxide MEDICATED BODY POWDER POWDER    
methyl salicylate/menth/camph MEDICATED RELIEF ADH. PATCH    
methyl salicylate/menth/camph PAIN RELIEVING PATCH ADH. PATCH    
methyl salicylate/menth/camph MUSCLE RUB ULTRA STRENGTH CREAM (G)    
methyl salicylate/menth/camph PAIN RELIEF CREAM (G)    
methyl salicylate/menth/camph PAIN RELIEVING CREAM (G)    
methyl salicylate/menth/camph NEURACIN GEL (GRAM)    
methyl salicylate/menth/camph PANALGESIC LOTION    
methyl salicylate/menthol MUSCLE RUB CREAM (G)    
methyl salicylate/menthol ARTHRICREAM HEAT CREAM (G)    
methyl salicylate/menthol EXTRA STRENGTH MUSCLE RUB CREAM (G)    
methyl salicylate/menthol PAIN RELIEVING CREAM CREAM (G)    
methyl salicylate/menthol PANALGESIC CREAM (G)    
methyl salicylate/menthol THERA-GESIC CREAM (G)    
methyl salicylate/menthol THERA-GESIC PLUS CREAM (G)    
methyl salicylate/menthol ULTRA STRENGTH MUSCLE RUB CREAM (G)    
methyl salicylate/menthol COLD AND HOT PAIN RELIEF CREAM (G)    
methyl salicylate/menthol CAPASIL CREAM(ML)    
methyl salicylate/menthol ANALGESIC BALM OINT. (G)    
methyl salicylate/menthol BACK RUB OINT. (G)    
methyl salicylate/menthol COLD & HOT PAIN RELIEF OINT. (G)    
methyl salicylate/menthol MUSCLE RUB OINT. (G)    
metronidazole ROSADAN CREAM (G)    
metronidazole NORITATE CREAM (G)    
metronidazole METROCREAM CREAM (G)    
metronidazole METRONIDAZOLE CREAM (G)    
metronidazole ROSADAN GEL (GRAM)    
metronidazole METROGEL GEL (GRAM)    
metronidazole METRONIDAZOLE GEL (GRAM)    
metronidazole METRONIDAZOLE LOTION    
metronidazole/skin cleanser 23 ROSADAN KIT CL-CRM    
metronidazole/skin cleanser 23 ROSADAN KIT CL-GEL    
minoxidil MINOXIDIL FOR MEN FOAM    
minoxidil HAIR REGROWTH TREATMENT SOLUTION    
minoxidil MINOXIDIL SOLUTION    
oxybenzone/cinoxate SOLBAR PF CREAM (G)    
oxybenzone/cinoxate SOLBAR PF LIQUID    
oxybenzone/cinoxate TI-SCREEN LOTION    
oxybenzone/octinox/sunscreen TI-SCREEN GEL (GRAM)    
oxybenzone/octinoxate TI-SCREEN LOTION    
oxybenzone/padimate O SUNBLOCK LOTION    
oxybenzone/pdo/petrolatum LIP TREATMENT W/SUNBLOCK 15 OINT. (G)    
oxymetazoline HCl RHOFADE CREAM (G)   May 25, 2017
parab/cet alc/stryl alc/pg/sls CETAPHIL CLEANSER    
phenol liquid CASTELLANI PAINT MODIFIED LIQUID    
phenol liquid PHENOL EZ MED. SWAB    
podofilox CONDYLOX GEL (GRAM)    
podofilox PODOFILOX SOLUTION    
podophyllum resin PODOCON-25 LIQUID    
pramoxine HCl/ammonium lactate AMLACTIN KIT    
pramoxine HCl/benzyl alcohol ITCH-X GEL (GRAM)    
pramoxine HCl/calamine CALDYPHEN LOTION    
pramoxine HCl/calamine CALAMINE PLUS LOTION    
pramoxine HCl/calamine CALADRYL LOTION    
pramoxine HCl/camph/zinc acet CLEAR MEDICATED LOTION LOTION    
pramoxine HCl/camph/zinc acet CALDYPHEN CLEAR LOTION    
pramoxine HCl/zinc acetate CALADRYL CLEAR LOTION    
pramoxine HCl/zinc acetate CALAMINE CLEAR LOTION    
pramoxine HCl/zinc acetate CALDYPHEN CLEAR LOTION    
pramoxine/zinc oxide/calamine DERMAGESIC CREAM (G)    
pramoxine/zinc oxide/calamine DERMAGESIC LOTION    
pyrithione zinc SHAMPOO PLUS SHAMPOO    
pyrithione zinc DHS ZINC SHAMPOO    
pyrithione zinc DANDRUFF SHAMPOO SHAMPOO    
resorcinol/sulfur PHISOAC BP CREAM (G)    
salicylic acid CORN REMOVER ADH. PATCH    
salicylic acid CALLUS REMOVERS ADH. PATCH    
salicylic acid WART REMOVER ADH. PATCH    
salicylic acid DERMACINRX ATRIX CLEANSER    
salicylic acid SALICYLIC ACID CREAM (G)    
salicylic acid DERMACINRX ATRIX CREAM(ML)    
salicylic acid SALICYLIC ACID FOAM    
salicylic acid SAL-PLANT GEL (GRAM)    
salicylic acid SALICYLIC ACID GEL (GRAM)    
salicylic acid SALICYLIC ACID LIQ-FILM    
salicylic acid CORN REMOVER LIQUID    
salicylic acid WART REMOVER LIQUID    
salicylic acid WART LIQUID LIQUID    
salicylic acid LIQUID CORN-CALLUS REMOVER LIQUID    
salicylic acid SALICYLIC ACID LOTION    
salicylic acid BENSAL HP OINT. (G)    
salicylic acid DHS SAL SHAMPOO    
salicylic acid THERAPEUTIC DANDRUFF SHAMPOO SHAMPOO    
salicylic acid/coal tar X-SEB T PEARL SHAMPOO    
salicylic acid/coal tar/sulfur SEBEX-T SHAMPOO    
salicylic acid/sulfur SEBEX SHAMPOO    
selenium sulfide SELENIUM SULFIDE LOTION    
selenium sulfide SELSUN GOLD FOR WOMEN SHAMPOO    
selenium sulfide SELSUN BLUE SHAMPOO    
selenium sulfide SELENIUM SULFIDE SHAMPOO    
selenium sulfide MEDICATED DANDRUFF SHAMPOO SHAMPOO    
selenium sulfide ANTI-DANDRUFF SHAMPOO    
selenium sulfide/aloe vera SELSUN BLUE SHAMPOO    
selenium sulfide/menthol SELSUN BLUE SHAMPOO    
silver nitrate applicator SILVER NITRATE APPLICATOR STICK (EA)    
skin cleanser CETAPHIL CLEANSER    
skin cleanser SEPTI-SOFT CLEANSER    
skin cleanser CATRIX CORRECTION CLEANSER    
skin cleanser AQUA GLYCOLIC CLEANSER    
skin cleanser comb no.19 ACUWASH CLEANSER    
skin cleanser comb no.40 REHYLA HAIR-BODY CLEANSER    
skin cleanser comb.no.23 REHYLA CLEANSER    
skin cleanser comb.no.26 CETAPHIL RESTORADERM CLEANSER    
soap CETAPHIL BAR    
soap OILATUM CAKE    
soap SENSI-CARE LIQ. SOAP    
sodium chloride SAF-CLENS SPRAY    
sodium chloride SODIUM CHLORIDE VIAL    
sulfacetamide sodium SODIUM SULFACETAMIDE CLEANSER    
sulfacetamide sodium OVACE PLUS CLEANSER    
sulfacetamide sodium OVACE CLEANSER    
sulfacetamide sodium SODIUM SULFACETAMIDE CLNSR GEL    
sulfacetamide sodium OVACE PLUS WASH CLNSR GEL    
sulfacetamide sodium OVACE PLUS CREAM (G)    
sulfacetamide sodium OVACE PLUS FOAM    
sulfacetamide sodium OVACE PLUS LOTION    
sulfacetamide sodium SODIUM SULFACETAMIDE SHAMPOO    
sulfacetamide sodium OVACE PLUS SHAMPOO    
sulfur SULPHO-LAC MED. SOAP    
surgical lubricant SURGILUBE JELLY (G)    
thrombin/fibrinog/aprotin/calc TISSEEL VHSD KIT    
thrombin/fibrinog/aprotin/calc ARTISS SYRINGE    
thrombin/fibrinog/aprotin/calc TISSEEL VHSD SYRINGE    
tretinoin/emollient base RENOVA PUMP CREAM (G)    
tretinoin/emollient base RENOVA CREAM (G)    
trolamine salicylate ANALGESIC BALM CREAM (G)    
trolamine salicylate ARTHRICREAM CREAM (G)    
trolamine salicylate SPORTS PAIN RELIEF CREAM (G)    
trolamine salicylate MOBISYL CREAM (G)    
trolamine salicylate PAIN RELIEVING CREAM (G)    
trolamine salicylate ARTHRI-LOTION LOTION    
urea UREA CREAM (G)    
urea UREA FOAM    
urea URAMAXIN FOAM    
urea UREA LOTION    
urea/camphor/menthol/eucalyptl TOETAL FRESH SOLUTION    
witch hazel WITCH HAZEL SOLUTION    
witch hazel leaf WITCH HAZEL LIQUID    
witch hazel leaf WITCH DOCTOR PAD    
witch hazel leaf WITCH HAZEL SOLUTION