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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 but eligible patients will encounter a co-pay at the pharmacy.
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 BENZOYL PEROXIDE FOAM Y    
benzoyl peroxide BP FOAM FOAM Y    
benzoyl peroxide BENZEPRO FOAM Y    
methoxsalen METHOXSALEN CAP LQ RAP N    
methoxsalen OXSORALEN-ULTRA CAP LQ RAP N    
metronidazole METROGEL GEL W/PUMP N    
metronidazole METRONIDAZOLE GEL W/PUMP N    
acitretin SORIATANE CAPSULE    
acitretin ACITRETIN CAPSULE    
alcohol/propylene glycol AQUAMED LOTION    
allantoin REMEDY 4-IN-1 BODY CLEANSER    
allantoin UNICARE MOISTURIZING LOTION    
aluminum chloride DRYSOL SOLUTION    
aluminum chloride XERAC AC SOLUTION    
aluminum oxide/hexachlorophene BRASIVOL CLEANSER    
avobenzone/octocryl/octyl sal CETAPHIL DERMACONTROL LOTION    
avobenzone/octocrylene CETAPHIL LOTION    
becaplermin REGRANEX GEL (GRAM) PA Document  
benzophenone/octinox/Dihd-Acet TI-SCREEN CREAM(ML)    
benzoyl perox/skin clnsr/emoll ACNEFREE SEVERE KIT    
benzoyl peroxide PANOXYL BAR    
benzoyl peroxide BENZOYL PEROXIDE CLEANSER    
benzoyl peroxide PANOXYL CLEANSER    
benzoyl peroxide PANOXYL CREAM (G)    
benzoyl peroxide DEL-AQUA-10 CREAM (G)    
benzoyl peroxide CLEARASIL DAILY CLEAR CREAM (G)    
benzoyl peroxide BENZOYL PEROXIDE LOTION    
benzoyl peroxide ACNE MEDICATION LOTION    
benzoyl peroxide/skin clnsr 24 ACNEFREE COMBO. PKG    
benzoyl peroxide/vit E mix INOVA COMBO. PKG    
bimatoprost BIMATOPROST DROP W/APP    
bimatoprost LATISSE DROP W/APP    
brimonidine tartrate MIRVASO GEL (GRAM)    
brimonidine tartrate MIRVASO GEL W/PUMP    
calcium acetate/aluminum sulf PEDI-BORO SOAK POWD PACK    
calcium acetate/aluminum sulf ASTRINGENT SOLUTION POWD PACK    
calcium carb/sod hypochlorite NAIL SCRUB LOTION    
camph/la/mo/phe/petrolat/paraf BLISTER-AID OINT. (G)    
camphor CAMPHOR SPIRIT    
camphor/alcohol ANTISEPTIC SKIN CLEANSER LIQUID    
camphor/phenol COLD SORE TREATMENT GEL (GRAM)    
camphor/phenol CAMPHO-PHENIQUE SOLUTION    
camphor/phenol INSTANT PAIN RELIEF SOLUTION    
camphor/phenol/petrolatum MEDICATED LIP OINT. (G)    
capsicum oleoresin/turp oil SLOANS LINIMENT    
ceramides 1,3,6-11 CERAVE CLEANSER    
ceramides 1,3,6-11/niacinamide CERAVE 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 ZONALON CREAM (G)    
doxepin HCl PRUDOXIN CREAM (G)    
doxepin HCl DOXEPIN HCL CREAM (G)    
edetate disodium/peg EYESCRUB PAD    
eflornithine HCl VANIQA CREAM (G)    
emollient base HYDROCREAM BASE CREAM (G)    
emollient base FORMULA 405 CREAM (G)    
emollient base DRY SKIN CREAM CREAM (G)    
emollient base DERMABASE CREAM (G)    
emollient base AQUA GLYCOLIC CREAM (G)    
emollient base CATRIX CORRECTION CREAM (G)    
emollient base PRETTY FEET & HANDS CREAM(ML)    
emollient base TOTEPHAN CREAM(ML)    
emollient combination no.43 PROMISEB CREAM (G)    
emollient combination no.85 LOUTREX CREAM (G)    
emollient no43/skin cleanser27 PROMISEB COMPLETE KIT CL-CRM    
eucalypt/men/camph/turp/wh.pet MEDICATED CHEST RUB OINT. (G)    
eucalyptus oil EUCALYPTUS OIL OIL    
eucalyptus oil/menthol/camphor CHEST RUB OINT. (G)    
fluocinolone/tretinoin/h-quin TRI-LUMA CREAM (G)    
foot deodorant comb. no.1 DESENEX AERO POWD    
glycerin AQUA GLYCOLIC SHAMPOO    
glycerin/aloe vera/witch hazel MEDICATED WIPES MED. PAD    
glycerin/aloe vera/witch hazel SANIPADS W/ALOE MED. PAD    
glycerin/witch hazel leaf PERIES 40 PADS MED. PAD    
glycerin/witch hazel leaf ANTISEPTIC CLEANSING PADS MED. PAD    
glycerin/witch hazel leaf FLEET MEDICATED WIPES MED. PAD    
glycerin/witch hazel leaf MEDI PADS MED. PAD    
glycerin/witch hazel leaf HYGIENIC CLEANSING PADS MED. PAD    
glycopyrronium tosylate QBREXZA TOWELETTE    
green soap GREEN SOAP TINCTURE    
hydrophilic cream HYDROPHILIC OINT. (G)    
hydrophilic ointment AQUABASE OINT. (G)    
hydrophilic ointment HYDROPHILIC OINT. (G)    
hydroquinone ESOTERICA FADE CREAM CREAM (G)    
hydroquinone HYDROQUINONE CREAM (G)    
hydroquinone microspheres HYDROQUINONE CRM ER (G)    
hydroquinone/oxybenzone/padima ESOTERICA FADE CREAM CREAM (G)    
ichthammol ICHTHAMMOL OINT. (G)    
imiquimod ZYCLARA CREAM PACK    
imiquimod ALDARA CREAM PACK    
imiquimod IMIQUIMOD CREAM PACK    
imiquimod IMIQUIMOD CRM MD PMP    
imiquimod ZYCLARA CRM MD PMP    
ivermectin SOOLANTRA CREAM (G)    
lanolin,anhydrous LANOLIN ANHYDROUS OINT. (G)    
m-salicy/aloe/menthol/eucalypt COATS ALOE ANALGESIC LINIMENT    
menthol COLD & HOT PAIN RELIEF ADH. PATCH    
menthol PAIN RELIEVING PATCH ADH. PATCH    
menthol WONDER ICE GEL (GRAM)    
menthol BLUE GEL GEL (GRAM)    
menthol DOLOXYL GEL (GRAM)    
menthol ICE BLUE GEL GEL (GRAM)    
menthol PAIN RELIEF GEL (GRAM)    
menthol PAIN RELIEVING GEL GEL (GRAM)    
menthol REFLEX PAIN RELIEF GEL (GRAM)    
menthol THERAPEUTIC MINERAL ICE GEL (GRAM)    
menthol THERAPEUTIC BLUE GEL GEL (GRAM)    
menthol COOL THERAPY GEL (ML)    
menthol/camphor CAMPHOTREX GEL W/APPL    
menthol/camphor ANTI-ITCH LOTION    
menthol/camphor SARNA LOTION    
menthol/camphor/phenol MEDICATED SKIN CREAM CREAM (G)    
menthol/zinc oxide MEDICATED BODY POWDER POWDER    
methyl salicylate/menth/camph MUSCLE RUB ULTRA STRENGTH CREAM (G)    
methyl salicylate/menth/camph PAIN RELIEF CREAM (G)    
methyl salicylate/menth/camph PANALGESIC LOTION    
methyl salicylate/menthol ARTHRICREAM HEAT CREAM (G)    
methyl salicylate/menthol ANALGESIC BALM CREAM (G)    
methyl salicylate/menthol PANALGESIC CREAM (G)    
methyl salicylate/menthol COLD AND HOT PAIN RELIEF CREAM (G)    
methyl salicylate/menthol EXTRA STRENGTH MUSCLE RUB CREAM (G)    
methyl salicylate/menthol MUSCLE RUB CREAM (G)    
methyl salicylate/menthol PAIN RELIEVING CREAM 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 ANALGESIC BALM OINT. (G)    
methyl salicylate/menthol BACK RUB OINT. (G)    
methyl salicylate/menthol COLD & HOT OINT. (G)    
methyl salicylate/menthol COLD & HOT PAIN RELIEF OINT. (G)    
methyl salicylate/menthol MUSCLE RUB OINT. (G)    
metronidazole METROCREAM CREAM (G)    
metronidazole ROSADAN CREAM (G)    
metronidazole NORITATE CREAM (G)    
metronidazole METRONIDAZOLE CREAM (G)    
metronidazole METROGEL GEL (GRAM)    
metronidazole ROSADAN GEL (GRAM)    
metronidazole METRONIDAZOLE GEL (GRAM)    
metronidazole METROLOTION LOTION    
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 SOLUTION    
minoxidil HAIR REGROWTH TREATMENT 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 CETA-KLENZ CLEANSER    
parab/cet alc/stryl alc/pg/sls CETAPHIL CLEANSER    
petrolatum,white LIP TREATMENT JELLY (G)    
petrolatum,white PETROLEUM JELLY JELLY (G)    
petrolatum,white WHITE PETROLATUM JELLY (G)    
phenol liquid CASTELLANI PAINT MODIFIED LIQUID    
phenol liquid PHENOL EZ MED. SWAB    
podofilox CONDYLOX GEL (GRAM)    
podofilox PODOFILOX SOLUTION    
podophyllum resin PODOCON-25 LIQUID    
polyethylene glycol POLYETHYLENE GLYCOL 8000 OINT. (G)    
pramoxine HCl/ammonium lactate AMLACTIN KIT    
pramoxine HCl/benzyl alcohol ITCH-X GEL (GRAM)    
pramoxine HCl/benzyl alcohol ITCH-X SPRAY    
pramoxine HCl/calamine CALADRYL LOTION    
pramoxine HCl/calamine CALAMINE MEDICATED LOTION    
pramoxine HCl/calamine CALDYPHEN LOTION    
pramoxine HCl/camph/zinc acet CALDYPHEN CLEAR LOTION    
pramoxine HCl/camph/zinc acet CLEAR MEDICATED LOTION LOTION    
pramoxine HCl/camph/zinc acet CALLERGY CLEAR LOTION    
pramoxine HCl/zinc acetate CALDYPHEN CLEAR LOTION    
pramoxine HCl/zinc acetate CALADRYL 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 ac/benzoyl per/vit E INOVA 4-1 COMBO. PKG    
salicylic ac/benzoyl per/vit E INOVA 8-2 COMBO. PKG    
salicylic acid CALLUS REMOVERS ADH. PATCH    
salicylic acid COMPOUND W ADH. PATCH    
salicylic acid CORN REMOVER ADH. PATCH    
salicylic acid WART REMOVER ADH. PATCH    
salicylic acid MEDIPLAST CORN-CALLUS-WART ADH. PATCH    
salicylic acid SALICYLIC ACID CREAM (G)    
salicylic acid SALICYLIC ACID FOAM    
salicylic acid SALICYLIC ACID GEL (GRAM)    
salicylic acid SAL-PLANT GEL (GRAM)    
salicylic acid COMPOUND W GEL (GRAM)    
salicylic acid SALICYLIC ACID LIQ-FILM    
salicylic acid WART LIQUID LIQUID    
salicylic acid CORN REMOVER LIQUID    
salicylic acid WART REMOVER LIQUID    
salicylic acid LIQUID CORN-CALLUS REMOVER LIQUID    
salicylic acid SCALP RELIEF LIQUID    
salicylic acid SALICYLIC ACID LOTION    
salicylic acid CLEARASIL DAILY CLEAR MED. PAD    
salicylic acid BENSAL HP OINT. (G)    
salicylic acid DHS SAL SHAMPOO    
salicylic acid SALEX SHAMPOO    
salicylic acid/ammon lact/aloe SALKERA FOAM    
salicylic acid/ceramide comb 1 SALEX COMBO. PKG    
salicylic acid/ceramide comb 1 SALEX KIT CLCMER    
salicylic acid/coal tar X-SEB T PEARL SHAMPOO    
salicylic acid/coal tar/sulfur ALA SEB T SHAMPOO    
salicylic acid/coal tar/sulfur SEBEX-T SHAMPOO    
salicylic acid/collodion, flex FREEZONE LIQUID    
salicylic acid/collodion, flex SALACTIC FILM LIQUID    
salicylic acid/glycerin DEL-STAT LOTION    
salicylic acid/isoprop.alcohol DEL-TRAC LOTION    
salicylic acid/sulfur ALA SEB SHAMPOO    
salicylic acid/sulfur SEBEX SHAMPOO    
selenium sulfide SELENIUM SULFIDE LOTION    
selenium sulfide ANTI-DANDRUFF SHAMPOO    
selenium sulfide SELENIUM SULFIDE SHAMPOO    
selenium sulfide SELSUN BLUE SHAMPOO    
selenium sulfide SELSUN GOLD FOR WOMEN SHAMPOO    
selenium sulfide/aloe vera SELSUN BLUE SHAMPOO    
selenium sulfide/menthol SELSUN BLUE SHAMPOO    
skin cleanser AQUA GLYCOLIC CLEANSER    
skin cleanser CATRIX CORRECTION CLEANSER    
skin cleanser CETAPHIL CLEANSER    
skin cleanser SEPTI-SOFT CLEANSER    
skin cleanser comb no.19 ACUWASH CLEANSER    
skin cleanser comb no.40 REHYLA HAIR-BODY CLEANSER    
skin cleanser comb.no.15 AQUANIL 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    
sulfacetamide sodium OVACE CLEANSER    
sulfacetamide sodium OVACE PLUS CLEANSER    
sulfacetamide sodium SODIUM SULFACETAMIDE 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 OVACE PLUS SHAMPOO    
sulfacetamide sodium SODIUM SULFACETAMIDE SHAMPOO    
sulfur SULPHO-LAC MED. SOAP    
surgical lubricant SURGILUBE JELLY (G)    
theobroma oil COCOA BUTTER CREAM (G)    
thrombin/fibrinog/aprotin/calc TISSEEL VHSD KIT    
thrombin/fibrinog/aprotin/calc ARTISS SYRINGE    
thrombin/fibrinog/aprotin/calc TISSEEL VHSD SYRINGE    
thymol/chlorophyllin CHLOROPHYLL TABLET    
tit dio/znox/homosa/octnx/mera CERAVE LOTION    
tretinoin ALTRENO LOTION    
tretinoin/emollient base RENOVA CREAM (G)    
tretinoin/emollient base RENOVA PUMP CREAM (G)    
trolamine salicylate TROLAMINE SALICYLATE CREAM (G)    
trolamine salicylate PAIN RELIEVING CREAM (G)    
trolamine salicylate MYOFLEX CREAM (G)    
trolamine salicylate SPORTS PAIN RELIEF CREAM (G)    
trolamine salicylate ANALGESIC BALM CREAM (G)    
trolamine salicylate ARTHRICREAM CREAM (G)    
trolamine salicylate MOBISYL CREAM (G)    
trolamine salicylate ARTHRI-LOTION LOTION    
urea METOPIC CREAM (G)    
urea REA LO 39 CREAM (G)    
urea REA LO 40 CREAM (G)    
urea UREACIN-20 CREAM (G)    
urea UREA CREAM (G)    
urea UMECTA EMULSN(G)    
urea KERAFOAM FOAM    
urea UMECTA FOAM    
urea URAMAXIN FOAM    
urea UREA FOAM    
urea UREA GEL (ML)    
urea URAMAXIN GEL (ML)    
urea DERMATOL 10 LOTION    
urea REA LO 40 LOTION    
urea UREA LOTION    
urea UREACIN-10 LOTION    
urea/camphor/menthol/eucalyptl TOETAL FRESH SOLUTION    
urea/emollient cmb no.18 DERMASORB XM CREAM (G)    
urea/lactic acid/zinc undecyl BP-50% UREA EMULSN(G)    
witch hazel WITCH HAZEL SOLUTION    
witch hazel leaf WITCH HAZEL LIQUID    
witch hazel leaf WITCH DOCTOR PAD    
witch hazel leaf WITCH HAZEL SOLUTION