Vaginal Cleansers
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 59365503000 | TRIMO-SAN | oxyquinoline/sod.lauryl sulfat | JELLY/APPL | 0.025 %-0.01 % | Y | ||
| 45802008255 | POVIDONE-IODINE | povidone-iodine | SOLUTION | 0.3 % | Y | ||
| 00132874302 | SUMMER'S EVE DOUCHE | povidone-iodine | SOLUTION | 0.3 % | Y | ||
| 00254085355 | POVIDONE-IODINE | povidone-iodine | SOLUTION | 10 % | Y | ||
| 00254085358 | POVIDONE-IODINE | povidone-iodine | SOLUTION | 10 % | Y | ||
| 00254085362 | POVIDONE-IODINE | povidone-iodine | SOLUTION | 10 % | Y | ||
| 00904110309 | POVIDONE-IODINE | povidone-iodine | SOLUTION | 10 % | Y | ||
| 24385005355 | POVIDONE-IODINE | povidone-iodine | SOLUTION | 10 % | Y | ||
| 45802005218 | POVIDONE-IODINE | povidone-iodine | SOLUTION | 10 % | Y | ||
| 70000006001 | POVIDONE-IODINE | povidone-iodine | SOLUTION | 10 % | Y | ||
| 70677120801 | POVIDONE-IODINE | povidone-iodine | SOLUTION | 10 % | Y | ||
| 82429020216 | POVIDONE-IODINE | povidone-iodine | SOLUTION | 10 % | Y |