Herpes Simplex

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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
ACYCLOVIR ZOVIRAX CAPSULE Y    
ACYCLOVIR ACYCLOVIR CAPSULE Y    
ACYCLOVIR ZOVIRAX ORAL SUSP Y    
ACYCLOVIR ACYCLOVIR ORAL SUSP Y    
ACYCLOVIR ACYCLOVIR TABLET Y    
ACYCLOVIR ZOVIRAX 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