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
ALOE VERA EXTRACT/ALLANTOIN COATS ALOE CREAM (G)    
ALOE VERA EXTRACT/ALLANTOIN COATS ALOE JELLY(ML)    
ALOE VERA EXTRACT/ALLANTOIN COATS ALOE MOISTURIZING LOTION    
AMMONIUM LACTATE AMMONIUM LACTATE CREAM (G)    
AMMONIUM LACTATE AMMONIUM LACTATE LOTION    
BENZETHON CL/PETROLATUM,WHITE SECURA COMBO. PKG    
BENZOIN BENZOIN TINCTURE    
CALAMINE/PHENOL LIQUID CALAMINE PHENOLATED LOTION    
CALAMINE/ZINC OXIDE CALAMINE LOTION    
CALAMINE/ZINC OXIDE/PHENOL LIQ CALAMINE SUSPENSION    
COD LIVER/VIT A,D/PETROLAT,WHT BAZA CLEAR OINT. (G)    
CORN STARCH SOOTHE & COOL BODY POWDER POWDER    
DIMETHICONE REMEDY CLEANSING BODY CLEANSER    
DIMETHICONE SECURA DIMETHICONE CREAM (G)    
DIMETHICONE SWEEN 24 CREAM (G)    
DIMETHICONE REMEDY NUTRASHIELD CREAM(ML)    
DIMETHICONE SOOTHE & COOL INZO BARRIER CREAM(ML)    
DIMETHICONE REMEDY SKIN REPAIR CREAM(ML)    
DIMETHICONE REMEDY DIMETHICONE CREAM(ML)    
DIMETHICONE MOISTUREL LOTION    
DIMETHICONE BAZA CLEANSE & PROTECT LOTION    
DIMETHICONE PROSHIELD PLUS OINT. (G)    
DIMETHICONE BAZA CLEANSE & PROTECT SPRAY    
DIMETHICONE/ZINC OXIDE BAZA PROTECT CREAM (G)    
DIMETHICONE/ZINC OXIDE INZO ZINC OXIDE BARRIER CREAM(ML)    
GLYCERIN GLYCERIN LIQUID    
GLYCERIN GLYCERIN SOLUTION    
LANOLIN SOOTHE AND COOL MEDSEPTIC OINT. (G)    
LANOLIN SOOTHE & COOL MEDSEPTIC OINT. (G)    
MENTHOL/ZINC OXIDE REMEDY CALAZIME PASTE (G)    
PETROLATUM,WHITE CARRINGTON MOISTURE BARRIER CREAM (G)    
PETROLATUM,WHITE WHITE PETROLATUM OINT PACK    
PETROLATUM,WHITE WHITE PETROLATUM OINT. (G)    
PETROLATUM,WHITE SECURA PROTECTIVE OINT. (G)    
PETROLATUM,WHITE ALOE VESTA OINT. (G)    
PETROLATUM/VIT A/VIT D3/E/ALOE SOOTHE & COOL MOIST BARRIER OINT. (G)    
TROLAMINE SALICYLATE/ALOE VERA ARTHRICREAM RUB CREAM (G)    
VIT E ACET/DMC/ZINC/PETROLAT CRITIC-AID CLEAR OINT. (G)    
VITAMINS A AND D VITAMIN A & D OINT. (G)    
VITS A AND D/WHITE PET/LANOLIN VITAMIN A AND D OINT PACK    
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 SECURA EXTRA PROTECTIVE CREAM (G)    
ZINC OXIDE SECURA PROTECTIVE CREAM (G)    
ZINC OXIDE Z-BUM CREAM (G)    
ZINC OXIDE ZINC OXIDE OINT. (G)    
ZINC OXIDE DR. SMITH'S DIAPER OINT. (G)    
ZINC OXIDE DIAPER RASH OINTMENT OINT. (G)    
ZINC OXIDE DR. SMITH'S DIAPER RASH SPRAY    
ZINC OXIDE DR. SMITH'S ADULT BARRIER 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 SOOTHE & COOL SKIN PASTE OINT. (G)