Sulfonamides

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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
MAFENIDE ACETATE SULFAMYLON CREAM (G)    
MAFENIDE ACETATE SULFAMYLON PACKET    
SILVER SULFADIAZINE SILVER SULFADIAZINE CREAM (G)    
SILVER SULFADIAZINE SILVADENE CREAM (G)    
SILVER SULFADIAZINE SSD CREAM (G)    
SULFACETAMIDE SOD/SULFUR/UREA CLEANSING WASH CLEANSER    
SULFACETAMIDE SOD/SULFUR/UREA SODIUM SULFACETAMIDE-SULFUR CLEANSER    
SULFACETAMIDE SODIUM/SULFUR SUMADAN CLEANSER PA Document  
SULFACETAMIDE SODIUM/SULFUR SUMAXIN CLEANSER PA Document  
SULFACETAMIDE SODIUM/SULFUR BP 10-1 CLEANSER PA Document  
SULFACETAMIDE SODIUM/SULFUR SODIUM SULFACETAMIDE-SULFUR CLEANSER PA Document  
SULFACETAMIDE SODIUM/SULFUR SODIUM SULFACETAMIDE-SULFUR CREAM (G) PA Document  
SULFACETAMIDE SODIUM/SULFUR SSS 10-5 CREAM (G) PA Document  
SULFACETAMIDE SODIUM/SULFUR SUMAXIN MED. PAD PA Document  
SULFACETAMIDE SODIUM/SULFUR SODIUM SULFACETAMIDE-SULFUR MED. PAD PA Document  
SULFACETAMIDE SODIUM/SULFUR SULFACLEANSE 8-4 SUSPENSION PA Document  
SULFACETAMIDE SODIUM/SULFUR SUMAXIN TS SUSPENSION PA Document  
SULFACETAMIDE SODIUM/SULFUR SODIUM SULFACETAMIDE-SULFUR SUSPENSION PA Document  
SULFACETAMIDE/SULFUR/CLEANSR23 SUMADAN KIT    
SULFACETAMIDE/SULFUR/CLEANSR23 SUMAXIN CP KIT    
SULFACT SOD/SULUR/AVOB/OTN/OCT SUMADAN XLT CMB CLN CR    
SULFADIAZINE SULFADIAZINE TABLET    
SULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM ORAL SUSP    
SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE-TRIMETHOPRIM ORAL SUSP    
SULFAMETHOXAZOLE/TRIMETHOPRIM BACTRIM TABLET    
SULFAMETHOXAZOLE/TRIMETHOPRIM BACTRIM DS TABLET    
SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET    
SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE-TRIMETHOPRIM VIAL    
SULFANILAMIDE AVC CREAM/APPL