Antifungals, Topical

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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
MICONAZOLE NITRATE ANTIFUNGAL CREAM CREAM (G) Y    
MICONAZOLE NITRATE MICATIN CREAM (G) Y    
MICONAZOLE NITRATE BAZA ANTIFUNGAL CREAM (G) Y    
MICONAZOLE NITRATE INZO ANTIFUNGAL CREAM (G) Y    
MICONAZOLE NITRATE ANTI-FUNGAL CREAM CREAM (G) Y    
MICONAZOLE NITRATE ANTIFUNGAL CREAM CREAM (G) Y    
MICONAZOLE NITRATE MICONAZOLE NITRATE CREAM (G) Y    
MICONAZOLE NITRATE MICONAZOLE NITRATE CREAM (G) Y    
MICONAZOLE NITRATE SECURA ANTIFUNGAL CREAM (G) Y    
MICONAZOLE NITRATE INZO ANTIFUNGAL CREAM (G) Y    
NYSTATIN NYSTATIN CREAM (G) Y    
NYSTATIN NYSTATIN OINT. (G) Y    
BUTENAFINE HCL MENTAX CREAM (G) N PA Document  
CICLOPIROX CICLOPIROX GEL (GRAM) N PA Document  
CICLOPIROX CICLOPIROX SHAMPOO N PA Document  
CICLOPIROX LOPROX SHAMPOO N PA Document  
CICLOPIROX CICLODAN SOLUTION N PA Document  
CICLOPIROX CICLOPIROX SOLUTION N PA Document  
CICLOPIROX PENLAC SOLUTION N PA Document  
CICLOPIROX OLAMINE LOPROX CREAM (G) N PA Document  
CICLOPIROX OLAMINE CICLODAN CREAM (G) N PA Document  
CICLOPIROX OLAMINE CICLOPIROX CREAM (G) N PA Document  
CICLOPIROX OLAMINE CICLOPIROX SUSPENSION N PA Document  
CICLOPIROX OLAMINE LOPROX SUSPENSION N PA Document  
CICLOPIROX/SKIN CLEANSER NO.28 CICLODAN COMBO. PKG N PA Document  
CICLOPIROX/SKIN CLEANSER NO.40 LOPROX COMBO. PKG N PA Document  
CICLOPIROX/SKIN CLEANSER NO.40 LOPROX KIT SS-CLN N PA Document  
CICLOPIROX/UREA/CAMPH/MEN/EUC CICLOPIROX SOLUTION N PA Document  
CICLOPIROX/UREA/CAMPH/MEN/EUC CICLODAN SOLUTION N PA Document  
CLOTRIMAZOLE CLOTRIMAZOLE CREAM (G) N PA Document  
CLOTRIMAZOLE ANTIFUNGAL CREAM (G) N PA Document  
CLOTRIMAZOLE ALEVAZOL OINT. (G) N PA Document  
CLOTRIMAZOLE CLOTRIMAZOLE SOLUTION N PA Document  
CLOTRIMAZOLE/BETAMETHASONE DIP LOTRISONE CREAM (G) N PA Document  
CLOTRIMAZOLE/BETAMETHASONE DIP CLOTRIMAZOLE-BETAMETHASONE CREAM (G) N PA Document  
CLOTRIMAZOLE/BETAMETHASONE DIP CLOTRIMAZOLE-BETAMETHASONE LOTION N PA Document  
ECONAZOLE NITRATE ECONAZOLE NITRATE CREAM (G) N PA Document  
EFINACONAZOLE JUBLIA SOL W/APPL N PA Document  
KETOCONAZOLE KETOCONAZOLE CREAM (G) N PA Document  
KETOCONAZOLE KETOCONAZOLE FOAM N PA Document  
KETOCONAZOLE EXTINA FOAM N PA Document  
KETOCONAZOLE KETOCONAZOLE SHAMPOO N PA Document  
KETOCONAZOLE NIZORAL SHAMPOO N PA Document  
LULICONAZOLE LUZU CREAM (G) N PA Document  
MICONAZOLE NITRATE MICONAZOLE NITRATE AERO POWD N PA Document  
MICONAZOLE NITRATE REMEDY ANTIFUNGAL CREAM(ML) N PA Document  
MICONAZOLE NITRATE FUNGOID TINCTURE KIT N PA Document  
MICONAZOLE NITRATE CRITIC-AID OINT. (G) N PA Document  
MICONAZOLE NITRATE DESENEX POWDER N PA Document  
MICONAZOLE NITRATE MICONAZORB AF POWDER N PA Document  
MICONAZOLE NITRATE MICRO-GUARD POWDER N PA Document  
MICONAZOLE NITRATE ZEASORB POWDER N PA Document  
MICONAZOLE NITRATE FUNGOID TINCTURE TINCTURE N PA Document  
MICONAZOLE NITRATE/ZINC OX/PET VUSION OINT. (G) N PA Document  
NAFTIFINE HCL NAFTIN CREAM (G) N PA Document  
NAFTIFINE HCL NAFTIFINE HCL CREAM (G) N PA Document  
NAFTIFINE HCL NAFTIN GEL (GRAM) N PA Document  
NYSTATIN NYAMYC POWDER N PA Document  
NYSTATIN NYSTATIN POWDER N PA Document  
NYSTATIN NYSTOP POWDER N PA Document  
NYSTATIN/TRIAMCIN NYSTATIN-TRIAMCINOLONE CREAM (G) N PA Document  
NYSTATIN/TRIAMCIN NYSTATIN-TRIAMCINOLONE OINT. (G) N PA Document  
OXICONAZOLE NITRATE OXICONAZOLE NITRATE CREAM (G) N PA Document  
OXICONAZOLE NITRATE OXISTAT CREAM (G) N PA Document  
OXICONAZOLE NITRATE OXISTAT LOTION N PA Document  
SERTACONAZOLE NITRATE ERTACZO CREAM (G) N PA Document  
SULCONAZOLE NITRATE EXELDERM CREAM (G) N PA Document  
SULCONAZOLE NITRATE EXELDERM SOLUTION N PA Document  
TAVABOROLE KERYDIN SOL W/APPL N PA Document  
TERBINAFINE LAMISIL AT GEL (GRAM) N PA Document  
TERBINAFINE HCL TERBINAFINE CREAM (G) N PA Document  
TERBINAFINE HCL ATHLETE'S FOOT CREAM (G) N PA Document  
TERBINAFINE HCL ATHLETE'S FOOT AF CREAM (G) N PA Document  
TERBINAFINE HCL LAMISIL AT CREAM (G) N PA Document  
TERBINAFINE HCL LAMISIL SPRAY N PA Document  
TOLNAFTATE LAMISIL AF AERO POWD N PA Document  
TOLNAFTATE ANTIFUNGAL AERO POWD N PA Document  
TOLNAFTATE JOCK ITCH AERO POWD N PA Document  
TOLNAFTATE ANTIFUNGAL CREAM CREAM (G) N PA Document  
TOLNAFTATE TOLNAFTATE CREAM (G) N PA Document  
TOLNAFTATE ANTI-FUNGAL POWDER N PA Document  
TOLNAFTATE TOLNAFTATE POWDER N PA Document  
TOLNAFTATE ATHLETE'S FOOT SPRAY N PA Document