Antiparasitics, 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
permethrin NIX COMPLETE COMBO. PKG Y    
permethrin ELIMITE CREAM (G) Y    
permethrin PERMETHRIN CREAM (G) Y    
permethrin LICE TREATMENT LIQUID Y    
permethrin LICE TREATMENT LIQUID Y    
permethrin PERMETHRIN LIQUID Y    
permethrin NIX LIQUID Y    
permethrin LICE KILLING LIQUID Y    
permethrin LICE CREAM RINSE LIQUID Y    
piperonyl butox/pyrethr/permet COMPLETE LICE TREATMENT KIT Y    
piperonyl butox/pyrethr/permet RID KIT Y    
piperonyl butox/pyrethr/permet LICE TREATMENT KIT Y    
piperonyl butox/pyrethr/permet LICE SOLUTION KIT Y    
piperonyl butox/pyrethr/permet LICE COMPLETE KIT 1-2-3 KIT Y    
piperonyl butox/pyrethr/permet A-200 LICE TREATMENT KIT Y    
piperonyl butox/pyrethr/permet LICE SOLUTION KIT Y    
piperonyl butoxide/pyrethrins INNOGEL PLUS GEL (GRAM) Y    
piperonyl butoxide/pyrethrins BLUE GEL GEL (GRAM) Y    
piperonyl butoxide/pyrethrins A-200 PYRINATE GEL (GRAM) Y    
piperonyl butoxide/pyrethrins TISIT GEL (GRAM) Y    
piperonyl butoxide/pyrethrins LICE COMBINATION KIT Y    
piperonyl butoxide/pyrethrins LICIDE TREATMENT KIT Y    
piperonyl butoxide/pyrethrins PRONTO KIT Y    
piperonyl butoxide/pyrethrins PEDICULICIDE 11 KIT Y    
piperonyl butoxide/pyrethrins A-200 PYRINATE KIT Y    
piperonyl butoxide/pyrethrins LICE TREATMENT KIT Y    
piperonyl butoxide/pyrethrins MEDI-LICE KIT Y    
piperonyl butoxide/pyrethrins PROTECT U-2000 KIT Y    
piperonyl butoxide/pyrethrins R & C KIT Y    
piperonyl butoxide/pyrethrins RID KIT Y    
piperonyl butoxide/pyrethrins TISIT KIT Y    
piperonyl butoxide/pyrethrins LICE CREME RINSE LIQUID Y    
piperonyl butoxide/pyrethrins LICE AWAY LIQUID Y    
piperonyl butoxide/pyrethrins EXTRA STRENGTH PYRINYL LIQUID Y    
piperonyl butoxide/pyrethrins LICE SHAMPOO LIQUID Y    
piperonyl butoxide/pyrethrins PIOJINA II LIQUID Y    
piperonyl butoxide/pyrethrins PEDICULICIDE LICE TREATMENT LIQUID Y    
piperonyl butoxide/pyrethrins PARATOX LIQUID Y    
piperonyl butoxide/pyrethrins MEDI-LICE LIQUID Y    
piperonyl butoxide/pyrethrins MAX STRENGTH LICE KILLING LIQUID Y    
piperonyl butoxide/pyrethrins LICE-X LIQUID Y    
piperonyl butoxide/pyrethrins LICETROL LIQUID Y    
piperonyl butoxide/pyrethrins LICE TREATMENT LIQUID Y    
piperonyl butoxide/pyrethrins END-LICE LIQUID Y    
piperonyl butoxide/pyrethrins PYRIN-X LIQUID Y    
piperonyl butoxide/pyrethrins RID LIQUID Y    
piperonyl butoxide/pyrethrins PYRETHRIN LIQUID Y    
piperonyl butoxide/pyrethrins PYRETHRIN LICE TREATMENT LIQUID Y    
piperonyl butoxide/pyrethrins PYRINYL LIQUID Y    
piperonyl butoxide/pyrethrins PYRINYL II LIQUID Y    
piperonyl butoxide/pyrethrins TISIT LIQUID Y    
piperonyl butoxide/pyrethrins LICE ELIMINATION SHAMPOO Y    
piperonyl butoxide/pyrethrins LICE COMBO SHAMPOO Y    
piperonyl butoxide/pyrethrins LICE PYRINYL SHAMPOO SHAMPOO Y    
piperonyl butoxide/pyrethrins A-200 LICE KILLING SHAMPOO Y    
piperonyl butoxide/pyrethrins HM MEDI-LICE SHAMPOO Y    
piperonyl butoxide/pyrethrins MEDI-LICE SHAMPOO Y    
piperonyl butoxide/pyrethrins LICE KILLING SHAMPOO Y    
piperonyl butoxide/pyrethrins LICIDE SHAMPOO Y    
piperonyl butoxide/pyrethrins LICETROL SHAMPOO Y    
piperonyl butoxide/pyrethrins LICE TREATMENT SHAMPOO Y    
piperonyl butoxide/pyrethrins PRONTO SHAMPOO Y    
piperonyl butoxide/pyrethrins LICE KILLING SHAMPOO Y    
piperonyl butoxide/pyrethrins LICE TREATMENT SHAMPOO Y    
piperonyl butoxide/pyrethrins PYRETHRIN SHAMPOO Y    
piperonyl butoxide/pyrethrins PYRINAL SHAMPOO Y    
piperonyl butoxide/pyrethrins RID SHAMPOO Y    
piperonyl butoxide/pyrethrins TEGRIN-LT LICE TREATMENT SHAMPOO Y    
piperonyl butoxide/pyrethrins TRIPLE X SHAMPOO Y    
piperonyl butoxide/pyrethrins R & C SHAMPOO Y    
crotamiton EURAX CREAM (G) N    
crotamiton EURAX LOTION N    
ivermectin SKLICE LOTION N    
lindane LINDANE SHAMPOO N    
malathion OVIDE LOTION N    
malathion MALATHION LOTION N    
spinosad NATROBA SUSPENSION N    
spinosad SPINOSAD SUSPENSION N