Herpes Simplex

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PDL Reference Documents

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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00904578961 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
00904751961 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
23155022901 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
23155022905 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
60505004206 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
61442011401 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
61442011405 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
62135003950 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
68084010701 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
68084010711 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
69076014601 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
71921014601 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
72241002805 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
72578000201 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
72578000205 ACYCLOVIR acyclovir CAPSULE 200 mg Y Y N  
00093363020 ACYCLOVIR acyclovir CREAM (G) 5 % N Y N Pharmacy PA
45802004475 ACYCLOVIR acyclovir CREAM (G) 5 % N Y N Pharmacy PA
51672136105 ACYCLOVIR acyclovir CREAM (G) 5 % N Y N Pharmacy PA
62332042305 ACYCLOVIR acyclovir CREAM (G) 5 % N Y N Pharmacy PA
65162083614 ACYCLOVIR acyclovir CREAM (G) 5 % N Y N Pharmacy PA
72578010105 ACYCLOVIR acyclovir CREAM (G) 5 % N Y N Pharmacy PA
71403004901 SITAVIG acyclovir MA BUC TAB 50 mg N Y N Pharmacy PA
00591115930 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
13668051501 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
13668051502 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
16714088501 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
16714088502 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
33342043930 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
51672136001 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
51672136002 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
65162083594 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
65162083596 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
68462074617 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
68462074635 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
70700010715 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
70700010716 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
72578008201 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
72578008206 ACYCLOVIR acyclovir OINT. (G) 5 % N Y N Pharmacy PA
00472008216 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL Y Y N  
23155048551 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL Y Y N  
31722068147 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL Y Y N  
59651049347 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL Y Y N  
62135080320 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL Y Y N  
62135080323 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL Y Y N  
62135080347 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL Y Y N  
70954018810 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL Y Y N  
72205017072 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL Y Y N  
72888007917 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL Y Y N  
62135080305 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL (5 mL) Y Y N  
62135080324 ACYCLOVIR acyclovir ORAL SUSP 200 mg/5 mL (5 mL) Y Y N  
00904750761 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
23155022701 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
23155022705 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
31722077701 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
31722077705 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
50268006111 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
50268006115 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
60505530601 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
60505530608 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
60687085601 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
60687085611 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
61442011201 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
61442011205 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
68382079101 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
68382079105 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
69367013701 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
69367013705 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
69452029020 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
69452029030 ACYCLOVIR acyclovir TABLET 400 mg Y Y N  
23155022801 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
23155022805 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
31722077801 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
31722077805 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
50268006211 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
50268006215 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
60505530701 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
60505530705 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
60687086701 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
60687086711 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
61442011301 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
61442011305 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
62135001950 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
68382079201 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
68382079205 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
69367013801 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
69367013805 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
69452029120 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
69452029130 ACYCLOVIR acyclovir TABLET 800 mg Y Y N  
00536142704 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
00713035302 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
00713035362 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
46122068107 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
46122080036 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
51672140602 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
51672140603 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
61269088135 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
61269098135 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
61269098937 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
70000051701 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
70677125501 DOCOSANOL docosanol CREAM (G) 10 % N Y N Pharmacy PA
00093811756 FAMCICLOVIR famciclovir TABLET 125 mg N Y N Pharmacy PA
31722070630 FAMCICLOVIR famciclovir TABLET 125 mg N Y N Pharmacy PA
33342002407 FAMCICLOVIR famciclovir TABLET 125 mg N Y N Pharmacy PA
60505324503 FAMCICLOVIR famciclovir TABLET 125 mg N Y N Pharmacy PA
64980034903 FAMCICLOVIR famciclovir TABLET 125 mg N Y N Pharmacy PA
00093811856 FAMCICLOVIR famciclovir TABLET 250 mg N Y N Pharmacy PA
31722070730 FAMCICLOVIR famciclovir TABLET 250 mg N Y N Pharmacy PA
33342002507 FAMCICLOVIR famciclovir TABLET 250 mg N Y N Pharmacy PA
60505324603 FAMCICLOVIR famciclovir TABLET 250 mg N Y N Pharmacy PA
64980035003 FAMCICLOVIR famciclovir TABLET 250 mg N Y N Pharmacy PA
00093811956 FAMCICLOVIR famciclovir TABLET 500 mg N Y N Pharmacy PA
31722070830 FAMCICLOVIR famciclovir TABLET 500 mg N Y N Pharmacy PA
33342002607 FAMCICLOVIR famciclovir TABLET 500 mg N Y N Pharmacy PA
60505324703 FAMCICLOVIR famciclovir TABLET 500 mg N Y N Pharmacy PA
64980035103 FAMCICLOVIR famciclovir TABLET 500 mg N Y N Pharmacy PA
00378972055 DENAVIR penciclovir CREAM (G) 1 % N Y N Pharmacy PA
00093318620 PENCICLOVIR penciclovir CREAM (G) 1 % N Y N Pharmacy PA
00378089655 PENCICLOVIR penciclovir CREAM (G) 1 % N Y N Pharmacy PA
13668066110 PENCICLOVIR penciclovir CREAM (G) 1 % N Y N Pharmacy PA
45802044075 PENCICLOVIR penciclovir CREAM (G) 1 % N Y N Pharmacy PA
00378427677 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
00378427693 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
16714069703 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
31722070505 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
31722070530 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
31722070590 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
50268078911 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
50268078915 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
57237004330 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
57237004390 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
59746032590 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
62135061430 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
62135061490 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
63304090530 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
63304090590 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
65862044930 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
65862044990 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
68084030911 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
68084030921 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
69097015402 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
69097015405 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
69097015412 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
69367026309 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
69367026330 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
82009004190 VALACYCLOVIR valacyclovir HCl TABLET 1,000 mg Y Y N  
00173056504 VALTREX valacyclovir HCl TABLET 1,000 mg Y Y N  
00173056510 VALTREX valacyclovir HCl TABLET 1,000 mg Y Y N  
00378427577 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
00378427593 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
00904656507 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
00904656561 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
16714069803 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
31722070430 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
31722070490 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
50268078811 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
50268078815 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
51079009301 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
51079009303 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
57237004230 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
57237004290 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
59746032490 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
62135061330 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
62135061390 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
63304090430 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
63304090490 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
65862044830 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
65862044890 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
68084021501 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
68084021511 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
68084021521 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
69367026209 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
69367026230 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
82009004030 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
82009004090 VALACYCLOVIR valacyclovir HCl TABLET 500 mg Y Y N  
00173093308 VALTREX valacyclovir HCl TABLET 500 mg Y Y N  
00173093310 VALTREX valacyclovir HCl TABLET 500 mg Y Y N  
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