Antifungals, Oral

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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
clotrimazole CLOTRIMAZOLE TROCHE Y    
fluconazole FLUCONAZOLE SUSP RECON Y    
fluconazole DIFLUCAN SUSP RECON Y    
fluconazole DIFLUCAN TABLET Y    
fluconazole FLUCONAZOLE TABLET Y    
nystatin NYSTATIN ORAL SUSP Y    
nystatin NYSTATIN TABLET Y    
flucytosine FLUCYTOSINE CAPSULE N PA Document  
flucytosine ANCOBON CAPSULE N PA Document  
griseofulvin ultramicrosize GRISEOFULVIN ULTRAMICROSIZE TABLET N PA Document  
griseofulvin ultramicrosize GRIS-PEG TABLET N PA Document  
griseofulvin, microsize GRISEOFULVIN ORAL SUSP N PA Document  
griseofulvin, microsize GRISEOFULVIN TABLET N PA Document  
isavuconazonium sulfate CRESEMBA CAPSULE N PA Document  
itraconazole ITRACONAZOLE CAPSULE N PA Document  
itraconazole SPORANOX CAPSULE N PA Document  
itraconazole SPORANOX SOLUTION N PA Document  
itraconazole ONMEL TABLET N PA Document  
ketoconazole KETOCONAZOLE TABLET N PA Document  
miconazole ORAVIG MA BUC TAB N PA Document  
posaconazole NOXAFIL ORAL SUSP N PA Document  
posaconazole NOXAFIL TABLET DR N PA Document  
terbinafine HCl LAMISIL TABLET N PA Document  
terbinafine HCl TERBINAFINE HCL TABLET N PA Document  
voriconazole VFEND SUSP RECON N PA Document  
voriconazole VORICONAZOLE SUSP RECON N PA Document  
voriconazole VFEND TABLET N PA Document  
voriconazole VORICONAZOLE TABLET N PA Document