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 FLUCONAZOLE TABLET Y    
FLUCONAZOLE DIFLUCAN 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 SPORANOX CAPSULE N PA Document  
ITRACONAZOLE ITRACONAZOLE 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 VORICONAZOLE SUSP RECON N PA Document  
VORICONAZOLE VFEND SUSP RECON N PA Document  
VORICONAZOLE VORICONAZOLE TABLET N PA Document  
VORICONAZOLE VFEND TABLET N PA Document