All Other Dermatologicals
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 & Updates |
|---|---|---|---|---|---|
| benzoyl peroxide micronized | BENZEPRO | TOWELETTE | Y | ||
| clascoterone | WINLEVI | CREAM (G) | N | ||
| ivermectin | SOOLANTRA | CREAM (G) | N | ||
| ivermectin | IVERMECTIN | 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 | |||
| avobenzone/octocrylene | CETAPHIL | LOTION | |||
| benzophenone/octinox/Dihd-Acet | TI-SCREEN | CREAM(ML) | |||
| bimatoprost | BIMATOPROST | DROP W/APP | |||
| bimatoprost | LATISSE | DROP W/APP | |||
| brimonidine tartrate | BRIMONIDINE TARTRATE | GEL W/PUMP | |||
| 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/petrolatum | MEDICATED LIP | OINT. (G) | |||
| cantharidin | YCANTH | SOL W/APPL | PA Document | Dec 07, 2023 | |
| capsaicin/menthol | MEDROX | ADH. PATCH | |||
| capsicum oleoresin | CAPSAICIN-CAPSICUM OLEORESIN | CREAM (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 | |||
| chlorcyclizine HCl/hydrocort | MANTADIL | CREAM (G) | |||
| chlorhexidine/glycerin/he-cell | MAXILUBE | JELLY (G) | |||
| diphenhydramine HCl | DIPHENHYDRAMINE HCL | CREAM (G) | |||
| diphenhydramine HCl | ANTI-ITCH | GEL (ML) | |||
| diphenhydramine HCl | DIPHENHYDRAMINE HCL | SPRAY | |||
| diphenhydramine HCl | ANTI-ITCH | SPRAY | |||
| diphenhydramine HCl/calamine | CALDYPHEN | LOTION | |||
| diphenhydramine HCl/zinc acet | BANOPHEN ANTI-ITCH | CREAM (G) | |||
| diphenhydramine HCl/zinc acet | ITCH RELIEF | CREAM (G) | |||
| diphenhydramine HCl/zinc acet | 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 | |||
| eucalyptus oil/menthol/camphor | CHEST RUB | OINT. (G) | |||
| fluocinolone/tretinoin/h-quin | TRI-LUMA | CREAM (G) | |||
| glycerin | AQUA GLYCOLIC | SHAMPOO | |||
| glycerin/witch hazel leaf | PERIES 40 PADS | MED. PAD | |||
| glycerin/witch hazel leaf | FLEET MEDICATED WIPES | MED. PAD | |||
| glycerin/witch hazel leaf | ANTISEPTIC CLEANSING PADS | MED. PAD | |||
| green soap | GREEN SOAP | TINCTURE | |||
| hydrophilic cream | HYDROPHILIC | OINT. (G) | |||
| hydroquinone | HYDROQUINONE | CREAM (G) | |||
| hydroquinone | ESOTERICA FADE CREAM | CREAM (G) | |||
| hydroquinone/oxybenzone/padima | ESOTERICA FADE CREAM | CREAM (G) | |||
| ichthammol | ICHTHAMMOL | OINT. (G) | |||
| m-salicy/aloe/menthol/eucalypt | COATS ALOE ANALGESIC | LINIMENT | |||
| menthol | COLD-HOT EXTRA STRENGTH | ADH. PATCH | |||
| menthol | MENTHOL COLD AND HOT | ADH. PATCH | |||
| menthol | PAIN RELIEF PATCH | ADH. PATCH | |||
| menthol | DOLOXYL | GEL (GRAM) | |||
| menthol | BLUE GEL | GEL (GRAM) | |||
| menthol | ICE BLUE GEL | GEL (GRAM) | |||
| menthol | PAIN RELIEF | GEL (GRAM) | |||
| menthol | REFLEX PAIN RELIEF | GEL (GRAM) | |||
| menthol | THERAPEUTIC BLUE GEL | GEL (GRAM) | |||
| menthol | WONDER ICE | GEL (GRAM) | |||
| menthol | COLD THERAPY | GEL (ML) | |||
| menthol | COOLING PAIN RELIEF | GEL (ML) | |||
| menthol | COOL-HEAT | LIQUID | |||
| 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) | |||
| methyl salicylate | METHYLTEN | CREAM (G) | |||
| methyl salicylate/menth/camph | PAIN RELIEVING PATCH | ADH. PATCH | |||
| methyl salicylate/menth/camph | MEDICATED RELIEF | ADH. PATCH | |||
| methyl salicylate/menth/camph | MENTICAM | CREAM (G) | |||
| methyl salicylate/menth/camph | MUSCLE RUB ULTRA STRENGTH | CREAM (G) | |||
| methyl salicylate/menth/camph | MENTICAM | GEL (GRAM) | |||
| methyl salicylate/menth/camph | NEURACIN | GEL (GRAM) | |||
| methyl salicylate/menth/camph | PANALGESIC | LOTION | |||
| methyl salicylate/menthol | ARTHRITIS PAIN RELIEF | ADH. PATCH | |||
| methyl salicylate/menthol | PAIN RELIEVING CREAM | CREAM (G) | |||
| methyl salicylate/menthol | ARTHRICREAM HEAT | CREAM (G) | |||
| methyl salicylate/menthol | EXTRA STRENGTH MUSCLE RUB | 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 | TRICYLATE | CREAM (G) | |||
| methyl salicylate/menthol | ULTRA STRENGTH MUSCLE RUB | CREAM (G) | |||
| methyl salicylate/menthol | MUSCLE RUB | CREAM (G) | |||
| methyl salicylate/menthol | CAPASIL | CREAM(ML) | |||
| methyl salicylate/menthol | MENCYLATE | CREAM(ML) | |||
| methyl salicylate/menthol | BACK RUB | OINT. (G) | |||
| methyl salicylate/menthol | MENTHODERM | OINT. (G) | |||
| methyl salicylate/menthol | MUSCLE RUB | OINT. (G) | |||
| methyl salicylate/menthol | ANALGESIC BALM | OINT. (G) | |||
| metronidazole | METROCREAM | CREAM (G) | |||
| metronidazole | METRONIDAZOLE | CREAM (G) | |||
| metronidazole | NORITATE | CREAM (G) | |||
| metronidazole | ROSADAN | CREAM (G) | |||
| metronidazole | METRONIDAZOLE | GEL (GRAM) | |||
| metronidazole | METROGEL | GEL (GRAM) | |||
| metronidazole | ROSADAN | 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 | MINOXIDIL FOR WOMEN | FOAM | |||
| minoxidil | GAINEXTRA HAIR REGROWTH | SOLUTION | |||
| 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 | ||
| phenol liquid | CASTELLANI PAINT MODIFIED | LIQUID | |||
| phenol liquid | PHENOL EZ | MED. SWAB | |||
| podofilox | PODOFILOX | GEL (GRAM) | |||
| podofilox | CONDYLOX | GEL (GRAM) | |||
| podofilox | PODOFILOX | SOLUTION | |||
| podophyllum resin | PODOCON-25 | LIQUID | |||
| pramoxine HCl/ammonium lactate | AMLACTIN | KIT | |||
| pramoxine HCl/calamine | CALAMINE MEDICATED | LOTION | |||
| pramoxine HCl/calamine | CALAMINE PLUS | LOTION | |||
| pramoxine HCl/calamine | CALDYPHEN | LOTION | |||
| pramoxine HCl/calamine | CALAMINE PLUS | SPRAY | |||
| pramoxine HCl/camph/zinc acet | CALDYPHEN CLEAR | LOTION | |||
| pramoxine HCl/camph/zinc acet | CLEAR MEDICATED LOTION | LOTION | |||
| pramoxine HCl/zinc acetate | CLEAR ANTI-ITCH | LOTION | |||
| pramoxine HCl/zinc acetate | CALDYPHEN CLEAR | LOTION | |||
| pramoxine HCl/zinc acetate | CALAMINE CLEAR | LOTION | |||
| pramoxine/zinc oxide/calamine | DERMAGESIC | CREAM (G) | |||
| pramoxine/zinc oxide/calamine | DERMAGESIC | LOTION | |||
| pyrithione zinc | DANDRUFF SHAMPOO | SHAMPOO | |||
| pyrithione zinc | DHS ZINC | SHAMPOO | |||
| pyrithione zinc | SHAMPOO PLUS | SHAMPOO | |||
| resorcinol/sulfur | PHISOAC BP | CREAM (G) | |||
| salicylic acid | CALLUS REMOVERS | ADH. PATCH | |||
| salicylic acid | CORN REMOVER | ADH. PATCH | |||
| salicylic acid | DERMACINRX ATRIX | CLEANSER | |||
| salicylic acid | SALYCIM | CREAM (G) | |||
| salicylic acid | DERMACINRX ATRIX | CREAM(ML) | |||
| salicylic acid | SALICYLIC ACID | FOAM | |||
| salicylic acid | SALICYLIC ACID | GEL (GRAM) | |||
| salicylic acid | SALICYLIC ACID | LIQ-FILM | |||
| salicylic acid | WART LIQUID | LIQUID | |||
| salicylic acid | WART REMOVER | LIQUID | |||
| salicylic acid | CORN REMOVER | LIQUID | |||
| salicylic acid | LIQUID CORN-CALLUS REMOVER | LIQUID | |||
| salicylic acid | SALICATE | LIQUID | |||
| salicylic acid | SALICYLIC ACID | OINT. (G) | |||
| salicylic acid | THERAPEUTIC DANDRUFF SHAMPOO | SHAMPOO | |||
| salicylic acid | DHS SAL | 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 BLUE | SHAMPOO | |||
| selenium sulfide | ANTI-DANDRUFF | SHAMPOO | |||
| selenium sulfide | MEDICATED DANDRUFF SHAMPOO | SHAMPOO | |||
| selenium sulfide | SELENIUM SULFIDE | SHAMPOO | |||
| selenium sulfide | SELSUN GOLD FOR WOMEN | SHAMPOO | |||
| selenium sulfide/aloe vera | SELSUN BLUE | SHAMPOO | |||
| selenium sulfide/menthol | SELSUN BLUE | SHAMPOO | |||
| silver nitrate applicator | SILVER NITRATE APPLICATOR | STICK (EA) | |||
| skin cleanser | SEPTI-SOFT | CLEANSER | |||
| skin cleanser | AQUA GLYCOLIC | CLEANSER | |||
| skin cleanser | CATRIX CORRECTION | CLEANSER | |||
| skin cleanser | CETAPHIL | CLEANSER | |||
| skin cleanser comb no.19 | ACUWASH | CLEANSER | |||
| skin cleanser comb no.40 | REHYLA HAIR-BODY | CLEANSER | |||
| skin cleanser comb no.42 | CETAPHIL GENTLE SKIN CLEANSER | CLEANSER | |||
| skin cleanser comb no.44 | CETAPHIL DAILY FACIAL CLEANSER | CLEANSER | |||
| skin cleanser comb.no.23 | REHYLA | CLEANSER | |||
| soap | CETAPHIL | BAR | |||
| soap | SENSI-CARE | LIQ. SOAP | |||
| sodium chloride | SAF-CLENS | SPRAY | |||
| sodium chloride | SODIUM CHLORIDE | VIAL | |||
| sofpironium bromide | SOFDRA | GEL W/PUMP | |||
| sulfacetamide sodium | OVACE | CLEANSER | |||
| sulfacetamide sodium | OVACE PLUS | CLEANSER | |||
| sulfacetamide sodium | SODIUM SULFACETAMIDE | CLEANSER | |||
| sulfacetamide sodium | OVACE PLUS WASH | CLNSR GEL | |||
| sulfacetamide sodium | SODIUM SULFACETAMIDE | CLNSR GEL | |||
| sulfacetamide sodium | OVACE PLUS | CREAM (G) | |||
| 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 | CREAM (G) | |||
| tretinoin/emollient base | RENOVA PUMP | CREAM (G) | |||
| trolamine salicylate | PAIN RELIEVING | CREAM (G) | |||
| trolamine salicylate | ANALGESIC BALM | CREAM (G) | |||
| trolamine salicylate | ARTHRICREAM | CREAM (G) | |||
| trolamine salicylate | ARTHRITIS | CREAM (G) | |||
| trolamine salicylate | ARTHRI-LOTION | LOTION | |||
| urea | UREA | CREAM (G) | |||
| urea | URAMAXIN | FOAM | |||
| urea | UREA | FOAM | |||
| urea/camphor/menthol/eucalyptl | TOETAL FRESH | SOLUTION | |||
| witch hazel | WITCH HAZEL | SOLUTION | |||
| witch hazel leaf | WITCH DOCTOR | PAD | |||
| witch hazel leaf | WITCH HAZEL | SOLUTION |