All Other Dermatologicals

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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.
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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
clascoterone WINLEVI CREAM (G) N   N  
ivermectin IVERMECTIN CREAM (G) N   N  
ivermectin SOOLANTRA CREAM (G) N   N  
methoxsalen METHOXSALEN CAP LQ RAP N   N  
metronidazole METRONIDAZOLE GEL W/PUMP N   N  
afamelanotide acetate SCENESSE IMPLANT   N  
avobenzone/octocrylene CETAPHIL LOTION   N  
bimatoprost LATISSE DROP W/APP   N  
brimonidine tartrate MIRVASO GEL W/PUMP   N  
calcium acetate/aluminum sulf ASTRINGENT SOLUTION POWD PACK   N  
camphor CAMPHOR SPIRIT   N  
camphor/phenol CAMPHO-PHENIQUE SOLUTION   N  
capsaicin/menthol MEDROX ADH. PATCH   N  
capsaicin/menthol DERMACINRX DIABECIN CS CREAM (G)   N  
capsicum oleoresin DERMACINRX CIRCATRIX CREAM (G)   N  
capsicum oleoresin/turp oil SLOANS LINIMENT   N  
chlorhexidine/glycerin/he-cell MAXILUBE JELLY (G)   N  
diphenhydramine HCl ANTI-ITCH SPRAY   N  
diphenhydramine HCl/calamine CALDYPHEN LOTION   N  
diphenhydramine HCl/zinc acet BANOPHEN ANTI-ITCH CREAM (G)   N  
diphenhydramine HCl/zinc acet ITCH RELIEF SPRAY   N  
doxepin HCl ZONALON CREAM (G)   N  
doxepin HCl PRUDOXIN CREAM (G)   N  
edetate disodium/peg EYESCRUB PAD   N  
glycerin/witch hazel leaf ANTISEPTIC CLEANSING PADS MED. PAD   N  
glycerin/witch hazel leaf PERIES 40 PADS MED. PAD   N  
hydrophilic cream HYDROPHILIC OINT. (G)   N  
hydroquinone HYDROQUINONE CREAM (G)   N  
ichthammol ICHTHAMMOL OINT. (G)   N  
menthol PAIN RELIEF PATCH ADH. PATCH   N  
menthol THERAPEUTIC BLUE GEL GEL (GRAM)   N  
menthol COOLING PAIN RELIEF GEL (ML)   N  
menthol COLD THERAPY GEL (ML)   N  
menthol COOL-HEAT LIQUID   N  
menthol/camphor CAMPHOTROL GEL W/APPL   N  
methyl salicylate METHYL SALICYLATE CREAM(ML)   N  
methyl salicylate/menth/camph PAIN RELIEVING PATCH ADH. PATCH   N  
methyl salicylate/menth/camph MENTICAM CREAM (G)   N  
methyl salicylate/menth/camph MUSCLE RUB ULTRA STRENGTH CREAM (G)   N  
methyl salicylate/menthol ULTRA STRENGTH MUSCLE RUB CREAM (G)   N  
methyl salicylate/menthol ARTHRICREAM HEAT CREAM (G)   N  
methyl salicylate/menthol TRICYLATE CREAM (G)   N  
methyl salicylate/menthol THERA-GESIC PLUS CREAM (G)   N  
methyl salicylate/menthol MENTHODERM OINT. (G)   N  
methyl salicylate/menthol MUSCLE RUB OINT. (G)   N  
metronidazole METROGEL GEL (GRAM)   N  
metronidazole METRONIDAZOLE GEL (GRAM)   N  
metronidazole ROSADAN GEL (GRAM)   N  
metronidazole METRONIDAZOLE LOTION   N  
metronidazole/skin cleanser 23 ROSADAN KIT CL-GEL   N  
minoxidil MINOXIDIL FOR WOMEN FOAM   N  
minoxidil MINOXIDIL FOR MEN FOAM   N  
minoxidil GAINEXTRA HAIR REGROWTH SOLUTION   N  
minoxidil HAIR REGROWTH TREATMENT SOLUTION   N  
oxybenzone/cinoxate SOLBAR PF CREAM (G)   N  
oxybenzone/padimate O SUNBLOCK LOTION   N  
podofilox PODOFILOX GEL (GRAM)   N  
podofilox PODOFILOX SOLUTION   N  
podophyllum resin PODOCON-25 LIQUID   N  
pramoxine HCl/ammonium lactate AMLACTIN KIT   N  
pramoxine HCl/calamine CALDYPHEN LOTION   N  
pramoxine HCl/calamine CALAMINE MEDICATED LOTION   N  
pramoxine HCl/calamine CALAMINE PLUS SPRAY   N  
pramoxine HCl/camph/zinc acet CALDYPHEN CLEAR LOTION   N  
pramoxine HCl/camph/zinc acet CLEAR MEDICATED LOTION LOTION   N  
pramoxine HCl/zinc acetate CALDYPHEN CLEAR LOTION   N  
pramoxine/zinc oxide/calamine DERMAGESIC CREAM (G)   N  
pyrithione zinc SHAMPOO PLUS SHAMPOO   N  
pyrithione zinc DANDRUFF SHAMPOO SHAMPOO   N  
salicylic acid SALYCIM CREAM (G)   N  
salicylic acid DERMACINRX ATRIX CREAM(ML)   N  
salicylic acid SALICYLIC ACID FOAM   N  
salicylic acid SALICYLIC ACID LIQ-FILM   N  
salicylic acid WART REMOVER LIQUID   N  
salicylic acid CORN REMOVER LIQUID   N  
salicylic acid WART LIQUID LIQUID   N  
salicylic acid/coal tar X-SEB T PEARL SHAMPOO   N  
salicylic acid/coal tar/sulfur SEBEX-T SHAMPOO   N  
salicylic acid/sulfur SEBEX SHAMPOO   N  
selenium sulfide SELSUN GOLD FOR WOMEN SHAMPOO   N  
selenium sulfide MEDICATED DANDRUFF SHAMPOO SHAMPOO   N  
selenium sulfide/menthol SELSUN BLUE SHAMPOO   N  
skin cleanser AQUA GLYCOLIC CLEANSER   N  
skin cleanser CETAPHIL CLEANSER   N  
skin cleanser comb no.19 ACUWASH CLEANSER   N  
skin cleanser comb no.42 CETAPHIL GENTLE SKIN CLEANSER CLEANSER   N  
skin cleanser comb no.44 CETAPHIL DAILY FACIAL CLEANSER CLEANSER   N  
soap SENSI-CARE LIQ. SOAP   N  
sodium chloride SODIUM CHLORIDE VIAL   N  
sulfacetamide sodium SODIUM SULFACETAMIDE CLNSR GEL   N  
sulfacetamide sodium OVACE PLUS WASH CLNSR GEL   N  
sulfacetamide sodium OVACE PLUS LOTION   N  
surgical lubricant SURGILUBE JELLY (G)   N  
thrombin/fibrinog/aprotin/calc TISSEEL VHSD SYRINGE   N  
trolamine salicylate ARTHRITIS CREAM (G)   N  
trolamine salicylate ARTHRICREAM CREAM (G)   N  
urea UREA CREAM (G)   N  
urea DERMACURE CREAM (G)   N  
urea UREA FOAM   N  
urea/camphor/menthol/eucalyptl TOETAL FRESH SOLUTION   N  
witch hazel leaf WITCH DOCTOR PAD   N  
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