Steroids, 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
alclometasone dipropionate ALCLOMETASONE DIPROPIONATE CREAM (G) Y    
alclometasone dipropionate ALCLOMETASONE DIPROPIONATE OINT. (G) Y    
betamethasone dipropionate BETAMETHASONE DIPROPIONATE CREAM (G) Y    
betamethasone dipropionate BETAMETHASONE DIPROPIONATE LOTION Y    
betamethasone dipropionate BETAMETHASONE DIPROPIONATE OINT. (G) Y    
betamethasone valerate BETAMETHASONE VALERATE CREAM (G) Y    
betamethasone valerate BETAMETHASONE VALERATE OINT. (G) Y    
clobetasol propionate CLOBETASOL PROPIONATE CREAM (G) Y    
clobetasol propionate TEMOVATE CREAM (G) Y    
clobetasol propionate CLOBETASOL PROPIONATE OINT. (G) Y    
clobetasol propionate TEMOVATE OINT. (G) Y    
desonide DESONIDE CREAM (G) Y    
desonide DESONIDE OINT. (G) Y    
fluocinolone acetonide FLUOCINOLONE ACETONIDE CREAM (G) Y    
fluocinolone acetonide SYNALAR CREAM (G) Y    
fluocinolone acetonide FLUOCINOLONE ACETONIDE SOLUTION Y    
fluocinolone acetonide SYNALAR SOLUTION Y    
fluocinonide VANOS CREAM (G) Y    
fluocinonide FLUOCINONIDE CREAM (G) Y    
fluocinonide FLUOCINONIDE SOLUTION Y    
fluocinonide/emollient base FLUOCINONIDE-E CREAM (G) Y    
fluocinonide/emollient base FLUOCINONIDE EMOLLIENT CREAM (G) Y    
hydrocortisone HYDROCORTISONE CREAM (G) Y 2.5 % Require PA  
hydrocortisone ANTI-ITCH CREAM (G) Y    
hydrocortisone PROCTOCORT CREAM (G) Y    
hydrocortisone PREPARATION H CREAM (G) Y    
hydrocortisone HYDROCORTISONE PLUS CREAM (G) Y    
hydrocortisone HYDROCORTISONE PLUS 12 CREAM (G) Y    
hydrocortisone HYDROCREAM CREAM (G) Y    
hydrocortisone HYTONE CREAM (G) Y    
hydrocortisone INSTACORT CREAM (G) Y    
hydrocortisone NOBLE FORMULA HC CREAM (G) Y    
hydrocortisone HYDROCORT CREAM (G) Y    
hydrocortisone RECORT CREAM (G) Y    
hydrocortisone RECORT PLUS CREAM (G) Y    
hydrocortisone SOOTHING CARE CREAM (G) Y    
hydrocortisone SUMMER'S EVE CREAM CREAM (G) Y    
hydrocortisone NEOSPORIN CREAM (G) Y    
hydrocortisone CORTIZONE FOR KIDS CREAM (G) Y    
hydrocortisone ANTI-ITCH CREAM (G) Y    
hydrocortisone BACTINE CREAM (G) Y    
hydrocortisone BETA HC CREAM (G) Y    
hydrocortisone CALDECORT CREAM (G) Y    
hydrocortisone COMPLEX A CREAM (G) Y    
hydrocortisone CORTAID CREAM (G) Y    
hydrocortisone CORTIZONE-10 CREAM (G) Y    
hydrocortisone CORTIZONE-10 PLUS CREAM (G) Y    
hydrocortisone CORTIZONE-5 CREAM (G) Y    
hydrocortisone DERMICORT CREAM (G) Y    
hydrocortisone DERMOLATE ANTI-ITCH CREAM (G) Y    
hydrocortisone ECZEMA ANTI-ITCH CREAM (G) Y    
hydrocortisone CORTISONE CREAM (G) Y    
hydrocortisone HYDROCORTISONE CREAM PACK Y    
hydrocortisone HYDROCORTISONE OINT. (G) Y    
hydrocortisone HYDROCORTISONE ACETATE OINT. (G) Y    
hydrocortisone HYDROCORT OINT. (G) Y    
hydrocortisone ANTI-ITCH OINT. (G) Y    
hydrocortisone HYDROCORTISONE OINT. (G) Y    
hydrocortisone CORTISONE OINT. (G) Y    
hydrocortisone CORTIZONE-10 OINT. (G) Y    
hydrocortisone CORTIZONE-5 OINT. (G) Y    
hydrocortisone acetate HYDROCORTISONE ACETATE CREAM (G) Y    
hydrocortisone acetate LANACORT CREAM (G) Y    
hydrocortisone acetate HYDROCORTISONE ACETATE CREAM (G) Y    
hydrocortisone acetate CORTICAINE CREAM (G) Y    
hydrocortisone acetate DERMAREST DRICORT CREAM (G) Y    
hydrocortisone acetate HM HYDROCORTISONE ACETATE CREAM (G) Y    
hydrocortisone acetate HYDROCORTISONE CREAM (G) Y    
hydrocortisone acetate GYNECORT CREAM (G) Y    
hydrocortisone acetate CORTICREME CREAM (G) Y    
hydrocortisone butyrate HYDROCORTISONE BUTYRATE SOLUTION Y    
triamcinolone acetonide TRIAMCINOLONE ACETONIDE CREAM (G) Y    
triamcinolone acetonide TRIANEX OINT. (G) Y    
triamcinolone acetonide TRIAMCINOLONE ACETONIDE OINT. (G) Y    
amcinonide AMCINONIDE CREAM (G) N    
amcinonide AMCINONIDE LOTION N    
betamethasone dipropionate BETAMETHASONE DIPROPIONATE GEL (GRAM) N    
betamethasone dipropionate SERNIVO SPRAY/PUMP N    
betamethasone valerate LUXIQ FOAM N    
betamethasone valerate BETAMETHASONE VALERATE FOAM N    
betamethasone valerate BETAMETHASONE VALERATE LOTION N    
betamethasone/propylene glyc BETAMETHASONE DIPROPIONATE CREAM (G) N    
betamethasone/propylene glyc BETAMETHASONE DIPROPIONATE LOTION N    
betamethasone/propylene glyc BETAMETHASONE DIPROPIONATE OINT. (G) N    
betamethasone/propylene glyc DIPROLENE OINT. (G) N    
clobetasol propionate CLOBETASOL PROPIONATE FOAM N    
clobetasol propionate OLUX FOAM N    
clobetasol propionate CLOBETASOL PROPIONATE GEL (GRAM) N    
clobetasol propionate CLOBETASOL PROPIONATE LOTION N    
clobetasol propionate CLOBEX LOTION N    
clobetasol propionate CLOBETASOL PROPIONATE SHAMPOO N    
clobetasol propionate CLODAN SHAMPOO N    
clobetasol propionate CLOBEX SHAMPOO N    
clobetasol propionate CLOBETASOL PROPIONATE SOLUTION N    
clobetasol propionate CLOBETASOL PROPIONATE SPRAY N    
clobetasol propionate CLOBEX SPRAY N    
clobetasol propionate/emoll CLOBETASOL EMOLLIENT CREAM (G) N    
clobetasol propionate/emoll OLUX-E FOAM N    
clobetasol propionate/emoll CLOBETASOL EMULSION FOAM N    
clobetasol propionate/emoll CLOBETASOL EMOLLIENT FOAM N    
clobetasol/skin cleanser no.28 CLODAN KT SHM CLN N    
clocortolone pivalate CLODERM CREAM (G) N    
clocortolone pivalate CLOCORTOLONE PIVALATE CREAM (G) N    
desonide DESONATE GEL (GRAM) N    
desonide DESONIDE LOTION N    
desoximetasone TOPICORT CREAM (G) N    
desoximetasone DESOXIMETASONE CREAM (G) N    
desoximetasone TOPICORT GEL (GRAM) N    
desoximetasone DESOXIMETASONE GEL (GRAM) N    
desoximetasone TOPICORT OINT. (G) N    
desoximetasone DESOXIMETASONE OINT. (G) N    
desoximetasone TOPICORT SPRAY N    
diflorasone diacetate PSORCON CREAM (G) N    
diflorasone diacetate DIFLORASONE DIACETATE CREAM (G) N    
diflorasone diacetate DIFLORASONE DIACETATE OINT. (G) N    
diflorasone diacetate/emoll APEXICON E CREAM (G) N    
fluocinolone acetonide DERMA-SMOOTHE-FS OIL N    
fluocinolone acetonide FLUOCINOLONE ACETONIDE OIL N    
fluocinolone acetonide FLUOCINOLONE ACETONIDE OINT. (G) N    
fluocinolone acetonide SYNALAR OINT. (G) N    
fluocinolone acetonide CAPEX SHAMPOO SHAMPOO N    
fluocinolone/emol comb no.65 SYNALAR CMB ONT CR N    
fluocinolone/emol comb no.65 SYNALAR CREAM (G) N    
fluocinolone/shower cap DERMA-SMOOTHE-FS OIL N    
fluocinolone/shower cap FLUOCINOLONE ACETONIDE OIL N    
fluocinolone/skin clnsr28 SYNALAR TS KIT N    
fluocinonide FLUOCINONIDE GEL (GRAM) N    
fluocinonide FLUOCINONIDE OINT. (G) N    
flurandrenolide FLURANDRENOLIDE CREAM (G) N    
flurandrenolide FLURANDRENOLIDE LOTION N    
flurandrenolide CORDRAN MED. TAPE N    
flurandrenolide FLURANDRENOLIDE OINT. (G) N    
fluticasone propionate FLUTICASONE PROPIONATE CREAM (G) N    
fluticasone propionate FLUTICASONE PROPIONATE LOTION N    
fluticasone propionate CUTIVATE LOTION N    
fluticasone propionate FLUTICASONE PROPIONATE OINT. (G) N    
halcinonide HALOG CREAM (G) N    
halcinonide HALOG OINT. (G) N    
halobetasol propionate ULTRAVATE CREAM (G) N    
halobetasol propionate HALOBETASOL PROPIONATE CREAM (G) N    
halobetasol propionate ULTRAVATE LOTION N    
halobetasol propionate ULTRAVATE OINT. (G) N    
halobetasol propionate HALOBETASOL PROPIONATE OINT. (G) N    
halobetasol/lactic acid ULTRAVATE X CMB ONT CR N    
halobetasol/lactic acid ULTRAVATE X COMBO. PKG N    
hydrocort/min oil/petrolat,wht HYDROCORTISONE OINT. (G) N    
hydrocortisone HYDROCORTISONE LOTION N    
hydrocortisone HYDRO SKIN LOTION N    
hydrocortisone TEXACORT SOLUTION N    
hydrocortisone SCALPICIN SOLUTION N    
hydrocortisone acetate MICORT-HC CRM/PE APP N    
hydrocortisone acetate/urea U-CORT CREAM (G) N    
hydrocortisone butyrate HYDROCORTISONE BUTYRATE CREAM (G) N    
hydrocortisone butyrate HYDROCORTISONE BUTYRATE OINT. (G) N    
hydrocortisone butyrate/emoll HYDROCORTISONE BUTYRATE CREAM (G) N    
hydrocortisone probutate PANDEL CREAM (G) N    
hydrocortisone valerate HYDROCORTISONE VALERATE CREAM (G) N    
hydrocortisone valerate HYDROCORTISONE VALERATE OINT. (G) N    
hydrocortisone/aloe vera HYDROSKIN CREAM (G) N    
hydrocortisone/aloe vera HYDROCORTISONE-ALOE CREAM (G) N    
hydrocortisone/aloe vera HYDROCORTISONE PLUS CREAM (G) N    
hydrocortisone/emollient no.45 PEDIADERM HC KT LOTN CE N    
mometasone furoate MOMETASONE FUROATE CREAM (G) N    
mometasone furoate ELOCON CREAM (G) N    
mometasone furoate ELOCON OINT. (G) N    
mometasone furoate MOMETASONE FUROATE OINT. (G) N    
mometasone furoate MOMETASONE FUROATE SOLUTION N    
neomyc/bacit/polymyx/hydrocort CORTISPORIN OINT. (G) N    
neomycin sulfate/fluocinolone NEO-SYNALAR CREAM (G) N    
neomycin/fluocinolone/emoll 65 NEO-SYNALAR CREAM (G) N    
prednicarbate PREDNICARBATE CREAM (G) N    
prednicarbate DERMATOP CREAM (G) N    
prednicarbate PREDNICARBATE OINT. (G) N    
prednicarbate DERMATOP OINT. (G) N    
triamcinolone acetonide TRIAMCINOLONE ACETONIDE AEROSOL N    
triamcinolone acetonide KENALOG AEROSOL N    
triamcinolone acetonide TRIAMCINOLONE ACETONIDE LOTION N    
triamcinolone/emollient cmb 45 PEDIADERM TA CREAM (G) N    
hydrocortisone PROCTOZONE-HC CRM/PE APP    
hydrocortisone PROCTOSOL-HC CRM/PE APP    
hydrocortisone PROCTO-PAK CRM/PE APP    
hydrocortisone PROCTO-MED HC CRM/PE APP    
hydrocortisone HYDROCORTISONE CRM/PE APP    
hydrocortisone ANUSOL-HC CRM/PE APP    
hydrocortisone acetate MICORT-HC CRM/PE APP    
neomycin/polymyxin B/hydrocort CORTISPORIN CREAM (G)