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 TEMOVATE CREAM (G) Y    
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CREAM (G) Y    
CLOBETASOL PROPIONATE TEMOVATE OINT. (G) Y    
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 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 SYNALAR SOLUTION Y    
FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE SOLUTION Y    
FLUOCINONIDE VANOS CREAM (G) Y    
FLUOCINONIDE FLUOCINONIDE CREAM (G) Y    
FLUOCINONIDE FLUOCINONIDE SOLUTION Y    
FLUOCINONIDE/EMOLLIENT BASE FLUOCINONIDE-E CREAM (G) Y    
HYDROCORTISONE ANTI-ITCH CREAM (G) Y    
HYDROCORTISONE PROCTOCORT CREAM (G) Y    
HYDROCORTISONE CORTIZONE-10 CREAM (G) Y    
HYDROCORTISONE ANTI-ITCH CREAM (G) Y    
HYDROCORTISONE CORTAID CREAM (G) Y    
HYDROCORTISONE CORTIZONE FOR KIDS CREAM (G) Y    
HYDROCORTISONE CORTIZONE-10 PLUS CREAM (G) Y    
HYDROCORTISONE CORTIZONE-5 CREAM (G) Y    
HYDROCORTISONE ECZEMA ANTI-ITCH CREAM (G) Y    
HYDROCORTISONE HYDROCORT CREAM (G) Y    
HYDROCORTISONE HYDROCREAM CREAM (G) Y    
HYDROCORTISONE NOBLE FORMULA HC CREAM (G) Y    
HYDROCORTISONE SOOTHING CARE CREAM (G) Y    
HYDROCORTISONE CORTISONE CREAM (G) Y    
HYDROCORTISONE HYDROCORTISONE CREAM (G) Y 2.5 % Require PA  
HYDROCORTISONE PREPARATION H CREAM (G) Y    
HYDROCORTISONE HYDROCORTISONE CREAM PACK Y    
HYDROCORTISONE HYDROCORTISONE OINT. (G) Y    
HYDROCORTISONE ANTI-ITCH OINT. (G) Y    
HYDROCORTISONE CORTIZONE-10 OINT. (G) Y    
HYDROCORTISONE HYDROCORT OINT. (G) Y    
HYDROCORTISONE HYDROCORTISONE OINT. (G) Y    
HYDROCORTISONE HYDROCORTISONE ACETATE OINT. (G) Y    
HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE CREAM (G) Y    
HYDROCORTISONE ACETATE DERMAREST DRICORT CREAM (G) Y    
HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE CREAM (G) Y    
HYDROCORTISONE BUTYRATE HYDROCORTISONE BUTYRATE SOLUTION Y    
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE CREAM (G) Y    
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE OINT. (G) Y    
TRIAMCINOLONE ACETONIDE TRIANEX OINT. (G) Y    
AMCINONIDE AMCINONIDE CREAM (G) N    
AMCINONIDE AMCINONIDE LOTION N    
AMCINONIDE AMCINONIDE OINT. (G) 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 OLUX FOAM N    
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE FOAM N    
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE GEL (GRAM) N    
CLOBETASOL PROPIONATE CLOBEX LOTION N    
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE LOTION N    
CLOBETASOL PROPIONATE CLOBEX SHAMPOO N    
CLOBETASOL PROPIONATE CLODAN SHAMPOO N    
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE SHAMPOO N    
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE SOLUTION N    
CLOBETASOL PROPIONATE CLOBEX SPRAY N    
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 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 DESOXIMETASONE GEL (GRAM) N    
DESOXIMETASONE TOPICORT GEL (GRAM) N    
DESOXIMETASONE DESOXIMETASONE OINT. (G) N    
DESOXIMETASONE TOPICORT 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 HALOBETASOL PROPIONATE CREAM (G) N    
HALOBETASOL PROPIONATE ULTRAVATE CREAM (G) N    
HALOBETASOL PROPIONATE ULTRAVATE LOTION N    
HALOBETASOL PROPIONATE HALOBETASOL PROPIONATE OINT. (G) N    
HALOBETASOL PROPIONATE ULTRAVATE OINT. (G) N    
HALOBETASOL/LACTIC ACID ULTRAVATE X CMB ONT CR N    
HALOBETASOL/LACTIC ACID ULTRAVATE X COMBO. PKG N    
HYDROCORTISONE HYDRO SKIN LOTION N    
HYDROCORTISONE HYDROCORTISONE LOTION N    
HYDROCORTISONE TEXACORT SOLUTION N    
HYDROCORTISONE SCALPICIN SOLUTION N    
HYDROCORTISONE ACETATE MICORT-HC CRM/PE APP 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 HYDROCORTISONE PLUS CREAM (G) N    
HYDROCORTISONE/ALOE VERA HYDROCORTISONE-ALOE CREAM (G) N    
HYDROCORTISONE/ALOE VERA HYDROSKIN CREAM (G) N    
MOMETASONE FUROATE ELOCON CREAM (G) N    
MOMETASONE FUROATE MOMETASONE FUROATE 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 DERMATOP CREAM (G) N    
PREDNICARBATE PREDNICARBATE CREAM (G) N    
PREDNICARBATE DERMATOP OINT. (G) N    
PREDNICARBATE PREDNICARBATE OINT. (G) N    
TRIAMCINOLONE ACETONIDE KENALOG AEROSOL N    
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE AEROSOL N    
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE LOTION N    
HYDROCORTISONE PROCTOSOL-HC CRM/PE APP    
HYDROCORTISONE ANUSOL-HC CRM/PE APP    
HYDROCORTISONE PROCTO-MED HC CRM/PE APP    
HYDROCORTISONE PROCTO-PAK CRM/PE APP    
HYDROCORTISONE PROCTOZONE-HC CRM/PE APP    
HYDROCORTISONE HYDROCORTISONE CRM/PE APP    
HYDROCORTISONE ACETATE MICORT-HC CRM/PE APP    
NEOMYCIN/POLYMYXIN B/HYDROCORT CORTISPORIN CREAM (G)