Antiparasitics, Topical
PDL Reference Documents
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.
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 | PERMETHRIN | CREAM (G) | Y | ||
| permethrin | PERMETHRIN | LIQUID | Y | ||
| permethrin | LICE TREATMENT | LIQUID | Y | ||
| permethrin | LICE KILLING | LIQUID | Y | ||
| permethrin | LICE TREATMENT | LIQUID | Y | ||
| permethrin | NIX | LIQUID | Y | ||
| permethrin | PERMETHRIN | LIQUID | Y | ||
| permethrin | LICE KILLING | LIQUID | Y | ||
| piperonyl but/pyrethins/permet | COMPLETE LICE TREATMENT | KIT | Y | ||
| piperonyl but/pyrethins/permet | COMPLETE LICE TREATMENT | KIT | Y | ||
| piperonyl but/pyrethins/permet | RID | KIT | Y | ||
| piperonyl but/pyrethins/permet | LICE SOLUTION | KIT | Y | ||
| piperonyl but/pyrethins/permet | LICE COMPLETE KIT 1-2-3 | KIT | Y | ||
| piperonyl butoxide/pyrethrins | TISIT | GEL (GRAM) | Y | ||
| piperonyl butoxide/pyrethrins | INNOGEL PLUS | GEL (GRAM) | Y | ||
| piperonyl butoxide/pyrethrins | TISIT | KIT | Y | ||
| piperonyl butoxide/pyrethrins | PRONTO | KIT | Y | ||
| piperonyl butoxide/pyrethrins | LICE TREATMENT | KIT | Y | ||
| piperonyl butoxide/pyrethrins | LICE TREATMENT | LIQUID | Y | ||
| piperonyl butoxide/pyrethrins | TISIT | LIQUID | Y | ||
| piperonyl butoxide/pyrethrins | PYRETHRIN LICE TREATMENT | LIQUID | Y | ||
| piperonyl butoxide/pyrethrins | PYRETHRIN | LIQUID | Y | ||
| piperonyl butoxide/pyrethrins | PIOJINA II | LIQUID | Y | ||
| piperonyl butoxide/pyrethrins | LICE CREME RINSE | LIQUID | Y | ||
| piperonyl butoxide/pyrethrins | LICE TREATMENT | SHAMPOO | Y | ||
| piperonyl butoxide/pyrethrins | LICE KILLING | SHAMPOO | Y | ||
| piperonyl butoxide/pyrethrins | RID | SHAMPOO | Y | ||
| piperonyl butoxide/pyrethrins | PRONTO | SHAMPOO | Y | ||
| piperonyl butoxide/pyrethrins | MEDI-LICE | SHAMPOO | Y | ||
| piperonyl butoxide/pyrethrins | LICE TREATMENT | SHAMPOO | Y | ||
| piperonyl butoxide/pyrethrins | LICE PYRINYL SHAMPOO | SHAMPOO | Y | ||
| piperonyl butoxide/pyrethrins | LICE KILLING | SHAMPOO | Y | ||
| piperonyl butoxide/pyrethrins | LICE ELIMINATION | SHAMPOO | Y | ||
| piperonyl butoxide/pyrethrins | LICETROL | SHAMPOO | Y | ||
| crotamiton | CROTAN | LOTION | N | ||
| ivermectin | SKLICE | LOTION | N | ||
| ivermectin | IVERMECTIN | LOTION | N | ||
| lindane | LINDANE | LOTION | N | ||
| lindane | LINDANE | SHAMPOO | N | ||
| malathion | MALATHION | LOTION | N | ||
| piperonyl butoxide/pyrethrins | VANALICE | GEL (ML) | N | ||
| spinosad | SPINOSAD | SUSPENSION | N | ||
| spinosad | NATROBA | SUSPENSION | N | ||
| sulfur | SULFUR | OINT. (G) | N |