Antiparasitics, Topical

← Back to Class List

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 PERMETHRIN LIQUID Y    
PERMETHRIN NIX LIQUID Y    
PERMETHRIN LICE TREATMENT LIQUID Y    
PERMETHRIN LICE KILLING LIQUID Y    
PERMETHRIN LICE TREATMENT LIQUID Y    
PIPERONYL BUTOX/PYRETHR/PERMET RID 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 COMPLETE LICE TREATMENT KIT Y    
PIPERONYL BUTOX/PYRETHR/PERMET LICE SOLUTION KIT Y    
PIPERONYL BUTOXIDE/PYRETHRINS TISIT GEL (GRAM) Y    
PIPERONYL BUTOXIDE/PYRETHRINS INNOGEL PLUS GEL (GRAM) Y    
PIPERONYL BUTOXIDE/PYRETHRINS PRONTO KIT Y    
PIPERONYL BUTOXIDE/PYRETHRINS LICE TREATMENT KIT Y    
PIPERONYL BUTOXIDE/PYRETHRINS TISIT KIT Y    
PIPERONYL BUTOXIDE/PYRETHRINS LICE TREATMENT LIQUID Y    
PIPERONYL BUTOXIDE/PYRETHRINS PIOJINA II LIQUID Y    
PIPERONYL BUTOXIDE/PYRETHRINS LICE CREME RINSE LIQUID Y    
PIPERONYL BUTOXIDE/PYRETHRINS PYRETHRIN LIQUID Y    
PIPERONYL BUTOXIDE/PYRETHRINS TISIT LIQUID Y    
PIPERONYL BUTOXIDE/PYRETHRINS PYRETHRIN LICE TREATMENT LIQUID Y    
PIPERONYL BUTOXIDE/PYRETHRINS LICE TREATMENT SHAMPOO Y    
PIPERONYL BUTOXIDE/PYRETHRINS LICETROL SHAMPOO Y    
PIPERONYL BUTOXIDE/PYRETHRINS MEDI-LICE SHAMPOO Y    
PIPERONYL BUTOXIDE/PYRETHRINS PRONTO SHAMPOO Y    
PIPERONYL BUTOXIDE/PYRETHRINS RID SHAMPOO Y    
PIPERONYL BUTOXIDE/PYRETHRINS LICE PYRINYL SHAMPOO SHAMPOO Y    
PIPERONYL BUTOXIDE/PYRETHRINS LICE ELIMINATION SHAMPOO Y    
PIPERONYL BUTOXIDE/PYRETHRINS LICE KILLING SHAMPOO Y    
PIPERONYL BUTOXIDE/PYRETHRINS LICE KILLING SHAMPOO Y    
PIPERONYL BUTOXIDE/PYRETHRINS LICE TREATMENT SHAMPOO Y    
CROTAMITON EURAX CREAM (G) N    
CROTAMITON EURAX LOTION N    
IVERMECTIN SKLICE LOTION N    
LINDANE LINDANE SHAMPOO N    
MALATHION MALATHION LOTION N    
MALATHION OVIDE LOTION N    
SPINOSAD NATROBA SUSPENSION N    
SPINOSAD SPINOSAD SUSPENSION N