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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
methoxsalen METHOXSALEN CAP LQ RAP N    
methoxsalen OXSORALEN-ULTRA CAP LQ RAP N    
metronidazole METROGEL GEL W/PUMP N    
metronidazole METRONIDAZOLE GEL W/PUMP N    
acitretin ACITRETIN CAPSULE    
acitretin SORIATANE CAPSULE    
adapalene DIFFERIN CREAM (G)    
adapalene ADAPALENE CREAM (G)    
adapalene DIFFERIN GEL (GRAM)    
adapalene ADAPALENE GEL (GRAM)    
adapalene DIFFERIN GEL W/PUMP    
adapalene ADAPALENE GEL W/PUMP    
adapalene DIFFERIN LOTION    
adapalene/benzoyl peroxide ADAPALENE-BENZOYL PEROXIDE GEL W/PUMP    
adapalene/benzoyl peroxide EPIDUO GEL W/PUMP    
adapalene/benzoyl peroxide EPIDUO FORTE GEL W/PUMP    
aluminum chloride XERAC AC SOLUTION    
azelaic acid AZELEX CREAM (G)    
azelaic acid FINACEA FOAM   Mar 31, 2016
azelaic acid FINACEA GEL (GRAM)    
azelaic acid/ceramide 1,3,6-11 FINACEA PLUS KIT    
becaplermin REGRANEX GEL (GRAM) PA Document  
benzoyl peroxide PANOXYL BAR    
benzoyl peroxide PANOXYL-4 CLEANSER    
benzoyl peroxide PANOXYL CLEANSER    
benzoyl peroxide BENZOYL PEROXIDE CLEANSER    
benzoyl peroxide PANOXYL CREAM (G)    
benzoyl peroxide BENZOYL PEROXIDE FOAM    
benzoyl peroxide ACNE MEDICATION GEL (GRAM)    
benzoyl peroxide BENZOYL PEROXIDE GEL (GRAM)    
benzoyl peroxide BPO GEL (GRAM)    
benzoyl peroxide ACNE MEDICATION LOTION    
benzoyl peroxide BPO TOWELETTE    
bimatoprost BIMATOPROST DROP W/APP    
brimonidine tartrate MIRVASO GEL (GRAM)    
brimonidine tartrate MIRVASO GEL W/PUMP    
calcium acetate/aluminum sulf ASTRINGENT SOLUTION POWD PACK    
calcium acetate/aluminum sulf PEDI-BORO SOAK POWD PACK    
camphor CAMPHOR SPIRIT    
camphor/phenol INSTANT PAIN RELIEF SOLUTION    
clindamycin phos/benzoyl perox CLINDAMYCIN PHOS-BENZOYL PEROX GEL (GRAM)    
clindamycin phos/benzoyl perox BENZACLIN GEL (GRAM)    
clindamycin phos/benzoyl perox CLINDAMYCIN-BENZOYL PEROXIDE GEL (GRAM)    
clindamycin phos/benzoyl perox DUAC GEL (GRAM)    
clindamycin phos/benzoyl perox NEUAC GEL (GRAM)    
clindamycin phos/benzoyl perox BENZACLIN GEL W/PUMP    
clindamycin phos/benzoyl perox CLINDAMYCIN-BENZOYL PEROXIDE GEL W/PUMP    
clindamycin phos/benzoyl perox ONEXTON GEL W/PUMP    
clindamycin phos/benzoyl perox ACANYA GEL W/PUMP    
clindamycin/benzoyl/emol cmb94 NEUAC CMB CR GEL    
clindamycin/tretinoin ZIANA GEL (GRAM)    
clindamycin/tretinoin CLINDAMYCIN PHOS-TRETINOIN GEL (GRAM)    
dapsone DAPSONE GEL (GRAM)    
dapsone ACZONE GEL (GRAM)    
dapsone ACZONE GEL W/PUMP    
diphenhydramine HCl ANTI-ITCH SPRAY    
diphenhydramine HCl/zinc acet ANTI-ITCH CREAM (G)    
diphenhydramine HCl/zinc acet BANOPHEN ANTI-ITCH CREAM (G)    
diphenhydramine HCl/zinc acet ITCH RELIEF CREAM (G)    
diphenhydramine HCl/zinc acet ITCH RELIEF SPRAY    
doxepin HCl PRUDOXIN CREAM (G)    
doxepin HCl ZONALON CREAM (G)    
doxepin HCl DOXEPIN HCL CREAM (G)    
eucalypt/men/camph/turp/wh.pet MEDICATED CHEST RUB OINT. (G)    
eucalyptus oil/menthol/camphor CHEST RUB OINT. (G)    
fluocinolone/tretinoin/h-quin TRI-LUMA CREAM (G)    
glycerin/witch hazel leaf HYGIENIC CLEANSING PADS MED. PAD    
glycerin/witch hazel leaf MEDI PADS MED. PAD    
hydroquinone HYDROQUINONE CREAM (G)    
hydroquinone microspheres HYDROQUINONE CRM ER (G)    
imiquimod ZYCLARA CREAM PACK    
imiquimod ALDARA CREAM PACK    
imiquimod IMIQUIMOD CREAM PACK    
imiquimod ZYCLARA CRM MD PMP    
isotretinoin ABSORICA CAPSULE    
isotretinoin MYORISAN CAPSULE    
isotretinoin CLARAVIS CAPSULE    
isotretinoin ZENATANE CAPSULE    
ivermectin SOOLANTRA CREAM (G)    
m-salicy/aloe/menthol/eucalypt COATS ALOE ANALGESIC LINIMENT    
menthol THERAPEUTIC BLUE GEL GEL (GRAM)    
menthol THERAPEUTIC MINERAL ICE GEL (GRAM)    
menthol BLUE GEL GEL (GRAM)    
menthol COOL THERAPY GEL (ML)    
menthol/camphor ANTI-ITCH LOTION    
menthol/camphor SARNA LOTION    
methyl salicylate/menthol THERA-GESIC PLUS CREAM (G)    
methyl salicylate/menthol MUSCLE RUB CREAM (G)    
methyl salicylate/menthol THERA-GESIC CREAM (G)    
methyl salicylate/menthol PAIN RELIEVING CREAM CREAM (G)    
methyl salicylate/menthol COLD & HOT OINT. (G)    
metronidazole METROCREAM CREAM (G)    
metronidazole METRONIDAZOLE CREAM (G)    
metronidazole ROSADAN CREAM (G)    
metronidazole NORITATE CREAM (G)    
metronidazole ROSADAN GEL (GRAM)    
metronidazole METROGEL GEL (GRAM)    
metronidazole METRONIDAZOLE GEL (GRAM)    
metronidazole METROLOTION LOTION    
metronidazole METRONIDAZOLE LOTION    
metronidazole/skin cleanser 23 ROSADAN KIT CL-CRM    
metronidazole/skin cleanser 23 ROSADAN KIT CL-GEL    
minoxidil MINOXIDIL SOLUTION    
minoxidil HAIR REGROWTH TREATMENT SOLUTION    
oxybenzone/cinoxate SOLBAR PF LIQUID    
oxymetazoline HCl RHOFADE CREAM (G)   May 25, 2017
petrolatum,white PETROLEUM JELLY JELLY (G)    
podofilox CONDYLOX GEL (GRAM)    
podofilox PODOFILOX SOLUTION    
podophyllum resin PODOCON-25 LIQUID    
pramoxine HCl/benzyl alcohol ITCH-X GEL (GRAM)    
pramoxine HCl/benzyl alcohol ITCH-X SPRAY    
pramoxine HCl/calamine CALAMINE MEDICATED LOTION    
pramoxine HCl/calamine CALDYPHEN LOTION    
pramoxine HCl/camph/zinc acet CALDYPHEN CLEAR LOTION    
pramoxine HCl/camph/zinc acet CALLERGY CLEAR LOTION    
pramoxine HCl/zinc acetate CALDYPHEN CLEAR LOTION    
pyrithione zinc DHS ZINC SHAMPOO    
salicylic acid SALICYLIC ACID FOAM    
salicylic acid SAL-PLANT GEL (GRAM)    
salicylic acid SALICYLIC ACID GEL (GRAM)    
salicylic acid SALICYLIC ACID LIQ-FILM    
salicylic acid SALICYLIC ACID LIQUID    
salicylic acid SCALP RELIEF LIQUID    
salicylic acid WART REMOVER LIQUID    
salicylic acid BENSAL HP OINT. (G)    
salicylic acid DHS SAL SHAMPOO    
salicylic acid SALEX SHAMPOO    
salicylic acid/ceramide comb 1 SALEX COMBO. PKG    
salicylic acid/ceramide comb 1 SALEX KIT CLCMER    
salicylic acid/collodion, flex SALACTIC FILM LIQUID    
salicylic acid/sulfur SEBEX SHAMPOO    
selenium sulfide SELENIUM SULFIDE LOTION    
selenium sulfide SELENIUM SULFIDE SHAMPOO    
selenium sulfide ANTI-DANDRUFF SHAMPOO    
skin cleanser DERMAL WOUND CLEANSER CLEANSER    
sulfacetamide sodium SODIUM SULFACETAMIDE CLEANSER    
sulfacetamide sodium SODIUM SULFACETAMIDE CLNSR GEL    
sulfacetamide sodium SULFACETAMIDE SODIUM SUSPENSION    
sulfacetamide sodium KLARON SUSPENSION    
tazarotene FABIOR FOAM PA Document  
thrombin/fibrinog/aprotin/calc TISSEEL VHSD KIT    
thrombin/fibrinog/aprotin/calc ARTISS SYRINGE    
thrombin/fibrinog/aprotin/calc TISSEEL VHSD SYRINGE    
tretinoin AVITA CREAM (G)    
tretinoin RETIN-A CREAM (G)    
tretinoin TRETINOIN CREAM (G)    
tretinoin ATRALIN GEL (GRAM)    
tretinoin AVITA GEL (GRAM)    
tretinoin RETIN-A GEL (GRAM)    
tretinoin TRETINOIN GEL (GRAM)    
tretinoin microspheres RETIN-A MICRO GEL (GRAM)    
tretinoin microspheres TRETINOIN MICROSPHERE GEL (GRAM)    
tretinoin microspheres TRETINOIN MICROSPHERE GEL W/PUMP    
tretinoin microspheres RETIN-A MICRO PUMP GEL W/PUMP    
tretinoin/emollient base RENOVA PUMP CREAM (G)    
tretinoin/emollient base RENOVA CREAM (G)    
trolamine salicylate ARTHRICREAM CREAM (G)    
trolamine salicylate MOBISYL CREAM (G)    
trolamine salicylate TROLAMINE SALICYLATE CREAM (G)    
urea UREA CREAM (G)    
urea UMECTA EMULSN(G)    
urea UMECTA FOAM    
urea UREA LOTION    
urea/lactic acid/zinc undecyl BP-50% UREA EMULSN(G)    
witch hazel WITCH HAZEL SOLUTION    
witch hazel leaf WITCH HAZEL LIQUID