Antifungals, Vaginal

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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
BUTOCONAZOLE NITRATE GYNAZOLE 1 CRM/PF APP    
CLOTRIMAZOLE CLOTRIMAZOLE CREAM/APPL    
CLOTRIMAZOLE 3-DAY VAGINAL CREAM CREAM/APPL    
CLOTRIMAZOLE CLOTRIMAZOLE-3 CREAM/APPL    
MICONAZOLE NITRATE MICONAZOLE NITRATE CREAM/APPL    
MICONAZOLE NITRATE 3 DAY VAGINAL CREAM/APPL    
MICONAZOLE NITRATE MICONAZOLE 7 CREAM/APPL    
MICONAZOLE NITRATE MICONAZOLE 3 KIT    
MICONAZOLE NITRATE MICONAZOLE 1 KIT    
MICONAZOLE NITRATE MICONAZOLE 7 SUPP.VAG    
MICONAZOLE NITRATE MICONAZOLE NITRATE SUPP.VAG    
MICONAZOLE NITRATE MICONAZOLE 3 SUPP.VAG    
TERCONAZOLE TERCONAZOLE CREAM/APPL    
TERCONAZOLE TERAZOL 7 CREAM/APPL    
TERCONAZOLE TERCONAZOLE SUPP.VAG    
TIOCONAZOLE TIOCONAZOLE-1 OIN/PF APP    
TIOCONAZOLE TIOCONAZOLE 1 OIN/PF APP