Emollients Protectives

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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
allantoin/onion/peg/water MEDERMA FOR KIDS GEL (GRAM)    
allantoin/onion/peg/water MEDERMA GEL (GRAM)    
aloe vera extract/allantoin COATS ALOE CREAM (G)    
aloe vera extract/allantoin COATS ALOE JELLY(ML)    
aloe vera extract/allantoin COATS ALOE LIQUID    
aloe vera extract/allantoin COATS ALOE MOISTURIZING LOTION    
aloe vera/petrolatum ALOE VESTA OINT. (G)    
aloe vera/soap ALOE VESTA LIQ. SOAP    
ammonium lactate AMMONIUM LACTATE CREAM (G)    
ammonium lactate AMLACTIN KIT    
ammonium lactate AMMONIUM LACTATE LOTION    
ammonium lactate LAC-HYDRIN FIVE LOTION    
ammonium lactate AMLACTIN LOTION    
ascorbic acid/cyclometh/dimeth CITRADERM CREAM (G)    
benzoin BENZOIN TINCTURE    
benzoin/aloe vera/storax/tolu COMPOUND BENZOIN TINCTURE    
bio/carb/equis/ethan/chit/msm GENADUR KIT    
calamine CALAMINE LOTION    
calamine/menthol/petrolat/zinc REMEDY CALAZIME PASTE (G)    
calamine/phenol liquid CALAMINE PHENOLATED LOTION    
calamine/zinc oxide CALAMINE LOTION    
calamine/zinc oxide/phenol liq CALAMINE SUSPENSION    
carbit/equis xt/ethan/chit/msm GENADUR LIQUID    
ceramide 1,3,6-11/B3/hyalur ac CERAVE PM LOTION ER    
ceramides 1,3,6-11 CERAVE CREAM (G)    
ceramides 1,3,6-11 CERAVE LOTION    
cetyl alc/stearyl alc/pg/sls CETAPHIL CREAM (G)    
cetyl alcohol/stearyl alcohol CAM LOTION    
cod liver oil/zinc oxide DIAPER RELIEF OINT. (G)    
cod liver/vit A,D/petrolat,wht BAZA CLEAR OINT. (G)    
cold cream COLD CREAM CREAM (G)    
cold cream/zinc oxide/star/lan DERMACLOUD OINT. (G)    
corn starch SOOTHE & COOL BODY POWDER POWDER    
dextranomer ENVISAN KIT    
dimethicone REMEDY CLEANSING BODY CLEANSER    
dimethicone PROSHIELD GLOVE CREAM (G)    
dimethicone SWEEN 24 CREAM (G)    
dimethicone SECURA DIMETHICONE CREAM (G)    
dimethicone THERASEAL CREAM (G)    
dimethicone REMEDY DIMETHICONE CREAM(ML)    
dimethicone REMEDY SKIN REPAIR CREAM(ML)    
dimethicone REMEDY NUTRASHIELD CREAM(ML)    
dimethicone SOOTHE & COOL INZO BARRIER CREAM(ML)    
dimethicone PROSHIELD GEL GEL (GRAM)    
dimethicone ALOE VESTA SKIN CONDITIONER 2 LOTION    
dimethicone BAZA CLEANSE & PROTECT LOTION    
dimethicone CERAVE LOTION    
dimethicone MOISTUREL LOTION    
dimethicone PROSHIELD PLUS OINT. (G)    
dimethicone BAZA CLEANSE & PROTECT SPRAY    
dimethicone BAZA CLEANSE & PROTECT TOWELETTE    
dimethicone/benzethonium chlor SECURA DIMETHICONE COMBO. PKG    
dimethicone/petrolatum,white SENSI-CARE MOISTURIZING 2 CREAM (G)    
dimethicone/zinc oxide BAZA PROTECT CREAM (G)    
dimethicone/zinc oxide INZO ZINC OXIDE BARRIER CREAM(ML)    
emollient combination no. 24 L-LYSINE OINT. (G)    
emollient combination no. 25 ELETONE CREAM (G)    
emollient combination no.10 BIAFINE EMULSN(G)    
emollient combination no.10 AVO CREAM EMULSN(G)    
emollient combination no.104 DEXERYL CREAM (G)    
emollient combination no.40 CETAPHIL LOTION    
emollient combination no.46 MEDERMA CREAM (G)    
emollient combination no.48 TROPAZONE LOTION    
emollient combination no.53 NIVATOPIC PLUS CREAM (G)    
emollient combination no.58 PEN-KERA CREAM(ML)    
emollient combination no.62 CETAPHIL RESTORADERM LOTION    
emollient combination no.65 KERADAN CREAM (G)    
gly/benzyl alc/petrolat,wht DML LOTION    
gly/dimeth/petrolat,wht/water CETAPHIL CREAM (G)    
glycer/dimeth/shea/stearyl alc CETAPHIL CREAM (G)    
glycerin GLYCERIN LIQUID    
glycerin GLYCERIN-ROSE WATER LIQUID    
glycerin GLYCERIN SOLUTION    
glycerin/boric acid LIQUA-GEL GEL (ML)    
glycerin/hyaluronate sodium OCEAN GEL (GRAM)    
glycerin/lan/min oil/aloe vera SOOTHE & COOL BODY LOTION LOTION    
glycerin/lanolin/methylbnz/sls XTRACARE LOTION    
glycerin/mineral oil EXTRA CARE SKIN LOTION LOTION    
glycerin/propylene glycol CANDERMYL CREAM (G)    
glycerin/zinc oxide/phenol liq OSTIDERM LOTION    
herbal drugs AQUA GLYCOLIC LOTION    
hyaluronate sodium BIONECT CREAM (G)    
hyaluronate sodium BIONECT FOAM    
hydrophilic cream BASLE CREAM (G)    
lactic acid LACTINOL HX CREAM (G)    
lactic acid/urea AQUA LACTEN LOTION    
lanolin SOOTHE AND COOL MEDSEPTIC OINT. (G)    
lanolin SOOTHE & COOL MEDSEPTIC OINT. (G)    
lanolin LANOLIN HYDROUS OINT. (G)    
lanolin/aloe vera/prop gly SOOTHE & COOL PERINEAL WASH LIQ. SOAP    
lanolin/aloe vera/prop gly SOOTHE & COOL LIQ. SOAP    
lanolin/mineral oil THERAPEUTIC BATH LIQUID    
lanolin/mineral oil EXTRA CARE HAND AND BODY LOTION    
lanolin/mineral oil HAND & BODY LOTION    
lanolin/mineral oil THERA-DERM LOTION    
lanolin/mineral oil THERA-P LOTION    
lanolin/mineral oil THERA-P HAND AND BODY LOTION LOTION    
lanolin/mineral oil THERAPEUTIC BATH OIL OIL    
lanolin/mineral oil NUTRADERM BATH OIL OIL    
lanolin/mineral oil THERA-DERM OIL    
lanolin/mineral oil BATH OIL OIL    
lanolin/petrolatum,white PH SKIN CLEANSER LIQUID    
lanolin/petrolatum,white PHISODERM LIQUID    
lanolin/zinc oxide D.R.C. PERI-RECTAL CREAM (G)    
lecithin/glycerin/dimethicone COMPLEX 15 CREAM (G)    
lecithin/glycerin/dimethicone COMPLEX 15 LOTION    
menthol/zinc oxide RISAMINE OINT. (G)    
menthol/zinc oxide REMEDY CALAZIME PASTE (G)    
mineral oil MAPO OIL    
mineral oil/hydrophil petrolat PETROLATUM OINT. (G)    
mineral oil/i-prop myr/water MOISTURIN LOTION    
mineral oil/i-prop myr/water MINERIN LOTION LOTION    
mineral oil/petrolat,wht/water LUBRISOFT LOTION    
mineral oil/petrolatum,white DERMALINE FORMULA CREAM (G)    
mineral oil/petrolatum,white MINERIN CREAM (G)    
mineral oil/petrolatum,white DERMALINE FORMULA LOTION    
mineral oil/petrolatum,white ABSORBASE OINT. (G)    
mineral oil/w.pet/alcohols/sls VELVACHOL CREAM (G)    
olive oil SWEET OIL OIL    
oxybenzone/sunscreen/hyalur ac DML FACIAL MOISTURIZER CREAM (G)    
pantot ac/glycerin/petrolatum DML FORTE CREAM (G)    
petrolatum,hydrophilic ALOE VESTA SPRAY    
petrolatum,white CARRINGTON MOISTURE BARRIER CREAM (G)    
petrolatum,white WHITE PETROLATUM OINT PACK    
petrolatum,white ALOE VESTA OINT. (G)    
petrolatum,white PETROLATUM OINT. (G)    
petrolatum,white REMEDY CLEAR-AID OINT. (G)    
petrolatum,white SECURA PROTECTIVE OINT. (G)    
petrolatum,white WHITE PETROLATUM OINT. (G)    
petrolatum,white REMEDY WITH PHYTOPLEX Z-GUARD PASTE (G)    
petrolatum,white/lanolin DR. SMITH'S RASH-SKIN OINT. (G)    
petrolatum/vit A/vit D3/E/aloe SOOTHE & COOL MOIST BARRIER OINT. (G)    
poly-ureaurethane NUVAIL NL FM SOLN    
sod chlord/lanolin/min.oil/pet DERMALUBE LOTION    
sod,ammonium,potassium lactate AMLACTIN CREAM (G)    
sod.bicarb/mbenz/starch/silica FORDUSTIN POWDER    
sodium chloride/potass/cal/mag HYDRISEA LOTION    
talc/cellulos/chloroxy/aldioxa ZEASORB POWDER    
titanium dioxide TI-BABY LOTION    
titanium dioxide TI-SCREEN LOTION    
trolamine salicylate/aloe vera ARTHRICREAM RUB CREAM (G)    
urea/alpha hydroxy acids ATRAC-TAIN CREAM (G)    
vit E acet/dmc/zinc/petrolat CRITIC-AID CLEAR OINT. (G)    
vit E acet/gly/dimeth/water CETAPHIL LOTION    
vit E acet/wheat germ/aloe v VITAMIN E OINT. (G)    
vitamin E VITAMIN E CREAM (G)    
vitamin E VITAMIN E OIL    
vitamin E VITAMIN E OIL OIL    
vitamin E/aloe vera ALOE E CREAM (G)    
vitamins A and D SWEEN CREAM CREAM (G)    
vitamins A and D SWEEN CREAM W/VITAMIN A & D CREAM (G)    
vitamins A and D VITAMIN A AND D CREAM (G)    
vitamins A and D VITAMIN A AND D OINT. (G)    
vitamins A and D/aloe vera SOOTHE & COOL SKIN CREAM CREAM (G)    
vitE ac/grape/hyaluronic acid ATOPICLAIR CREAM (G)    
vits A and D/white pet/lanolin VITAMIN A AND D OINT PACK    
vits A and D/white pet/lanolin VITAMIN A AND D OINT. (G)    
vits A and D/white pet/lanolin VITAMIN A & D OINT. (G)    
y.petrolatum/A and D/aloe vera SOOTHE & COOL MOIST BARRIER OINT. (G)    
zinc oxide Z-BUM CREAM (G)    
zinc oxide SECURA EXTRA PROTECTIVE CREAM (G)    
zinc oxide SECURA PROTECTIVE CREAM (G)    
zinc oxide DIAPER RASH OINT. (G)    
zinc oxide DIAPER RASH OINTMENT OINT. (G)    
zinc oxide DR. SMITH'S DIAPER OINT. (G)    
zinc oxide ZINC OXIDE OINT. (G)    
zinc oxide LASSAR'S PASTE PASTE (G)    
zinc oxide ZINC OXIDE PASTE (G)    
zinc oxide YEAST-X POWDER    
zinc oxide DR. SMITH'S ADULT BARRIER SPRAY    
zinc oxide DR. SMITH'S DIAPER RASH SPRAY    
zinc oxide DR. SMITH'S RASH-SKIN SPRAY    
zinc oxide/benzethonium chlor SECURA COMBO. PKG    
zinc oxide/petrolatum, yellow CRITIC-AID PASTE (G)    
zinc oxide/petrolatum,white CARRINGTON MOISTURE BARRIER CREAM (G)    
zinc oxide/petrolatum,white SKINTEGRITY CREAM (G)    
zinc oxide/petrolatum,white SENSI-CARE OINT. (G)    
zinc oxide/petrolatum,white SOOTHE & COOL SKIN PASTE OINT. (G)    
zinc oxide/petrolatum,white REMEDY PHYTOPLEX Z-GUARD PASTE (G)