Herpes Simplex

← 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
acyclovir ACYCLOVIR CAPSULE Y    
acyclovir ZOVIRAX CAPSULE Y    
acyclovir ZOVIRAX ORAL SUSP Y    
acyclovir ACYCLOVIR ORAL SUSP Y    
acyclovir ZOVIRAX TABLET Y    
acyclovir ACYCLOVIR TABLET Y    
acyclovir ZOVIRAX CREAM (G) N PA Document  
acyclovir SITAVIG MA BUC TAB N PA Document  
acyclovir ZOVIRAX OINT. (G) N PA Document  
acyclovir ACYCLOVIR OINT. (G) N PA Document  
acyclovir/hydrocortisone XERESE CREAM (G) N PA Document  
docosanol ABREVA CREAM (G) N PA Document  
famciclovir FAMCICLOVIR TABLET N PA Document  
penciclovir DENAVIR CREAM (G) N PA Document  
valacyclovir HCl VALTREX TABLET N PA Document  
valacyclovir HCl VALACYCLOVIR TABLET N PA Document  
letermovir PREVYMIS TABLET