Antifungals, Oral

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PDL Reference Documents

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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
00054414622 CLOTRIMAZOLE clotrimazole TROCHE 10 mg Y Y  
00054414623 CLOTRIMAZOLE clotrimazole TROCHE 10 mg Y Y  
00574010714 CLOTRIMAZOLE clotrimazole TROCHE 10 mg Y Y  
00574010770 CLOTRIMAZOLE clotrimazole TROCHE 10 mg Y Y  
00574010777 CLOTRIMAZOLE clotrimazole TROCHE 10 mg Y Y  
16571068607 CLOTRIMAZOLE clotrimazole TROCHE 10 mg Y Y  
16571068614 CLOTRIMAZOLE clotrimazole TROCHE 10 mg Y Y  
16714069501 FLUCONAZOLE fluconazole SUSP RECON 10 mg/mL Y Y  
57237014935 FLUCONAZOLE fluconazole SUSP RECON 10 mg/mL Y Y  
59762502901 FLUCONAZOLE fluconazole SUSP RECON 10 mg/mL Y Y  
00049345019 DIFLUCAN fluconazole SUSP RECON 40 mg/mL Y Y  
16714069601 FLUCONAZOLE fluconazole SUSP RECON 40 mg/mL Y Y  
57237015035 FLUCONAZOLE fluconazole SUSP RECON 40 mg/mL Y Y  
59762503001 FLUCONAZOLE fluconazole SUSP RECON 40 mg/mL Y Y  
70436022748 FLUCONAZOLE fluconazole SUSP RECON 40 mg/mL Y Y  
00904650006 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
00904650061 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
16714069101 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
16714069102 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
50268033711 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
50268033715 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
55111014401 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
55111014430 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
57237000430 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
62135013130 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
62559099130 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
68001025204 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
68084072801 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
68084072811 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
68462010230 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
70710113801 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
70710113803 FLUCONAZOLE fluconazole TABLET 100 mg Y Y  
16714069210 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
16714069211 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
55111014512 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
55111014571 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
57237000511 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
62135013277 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
62559099212 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
68001025317 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
68001025344 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
68462011940 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
68462011944 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
70710113907 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
70710113908 FLUCONAZOLE fluconazole TABLET 150 mg Y Y  
00904650106 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
00904650161 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
16714069301 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
16714069302 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
50268033911 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
50268033915 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
55111014601 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
55111014630 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
57237000601 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
57237000630 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
62135013330 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
62559099330 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
63739011510 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
68001025404 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
68084073501 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
68084073511 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
68462010430 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
70710114001 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
70710114003 FLUCONAZOLE fluconazole TABLET 200 mg Y Y  
16714069401 FLUCONAZOLE fluconazole TABLET 50 mg Y Y  
55111014301 FLUCONAZOLE fluconazole TABLET 50 mg Y Y  
55111014330 FLUCONAZOLE fluconazole TABLET 50 mg Y Y  
57237000330 FLUCONAZOLE fluconazole TABLET 50 mg Y Y  
60505011901 FLUCONAZOLE fluconazole TABLET 50 mg Y Y  
62135013030 FLUCONAZOLE fluconazole TABLET 50 mg Y Y  
62559099030 FLUCONAZOLE fluconazole TABLET 50 mg Y Y  
68001025104 FLUCONAZOLE fluconazole TABLET 50 mg Y Y  
68462010130 FLUCONAZOLE fluconazole TABLET 50 mg Y Y  
70710113703 FLUCONAZOLE fluconazole TABLET 50 mg Y Y  
00187355410 ANCOBON flucytosine CAPSULE 250 mg N Y PA Document
00904683407 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
23155086001 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
23155086003 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
42494033901 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
42494033903 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
42794000908 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
43386077101 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
50268033111 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
50268033112 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
59651033101 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
60687059911 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
60687059921 FLUCYTOSINE flucytosine CAPSULE 250 mg N Y PA Document
00187355510 ANCOBON flucytosine CAPSULE 500 mg N Y PA Document
00904683507 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
23155086101 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
23155086103 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
42494034001 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
42494034003 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
42794001008 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
43386077001 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
50268033211 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
50268033212 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
59651033201 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
60687061011 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
60687061021 FLUCYTOSINE flucytosine CAPSULE 500 mg N Y PA Document
00115172401 GRISEOFULVIN ULTRAMICROSIZE griseofulvin ultramicrosize TABLET 125 mg N Y PA Document
23155086301 GRISEOFULVIN ULTRAMICROSIZE griseofulvin ultramicrosize TABLET 125 mg N Y PA Document
42794001308 GRISEOFULVIN ULTRAMICROSIZE griseofulvin ultramicrosize TABLET 125 mg N Y PA Document
62135049401 GRISEOFULVIN ULTRAMICROSIZE griseofulvin ultramicrosize TABLET 125 mg N Y PA Document
62135049430 GRISEOFULVIN ULTRAMICROSIZE griseofulvin ultramicrosize TABLET 125 mg N Y PA Document
00115172501 GRISEOFULVIN ULTRAMICROSIZE griseofulvin ultramicrosize TABLET 250 mg N Y PA Document
00781582801 GRISEOFULVIN ULTRAMICROSIZE griseofulvin ultramicrosize TABLET 250 mg N Y PA Document
23155086401 GRISEOFULVIN ULTRAMICROSIZE griseofulvin ultramicrosize TABLET 250 mg N Y PA Document
42794001408 GRISEOFULVIN ULTRAMICROSIZE griseofulvin ultramicrosize TABLET 250 mg N Y PA Document
62135049501 GRISEOFULVIN ULTRAMICROSIZE griseofulvin ultramicrosize TABLET 250 mg N Y PA Document
62135049530 GRISEOFULVIN ULTRAMICROSIZE griseofulvin ultramicrosize TABLET 250 mg N Y PA Document
00472001304 GRISEOFULVIN griseofulvin, microsize ORAL SUSP 125 mg/5 mL N Y PA Document
00713085004 GRISEOFULVIN griseofulvin, microsize ORAL SUSP 125 mg/5 mL N Y PA Document
62135096841 GRISEOFULVIN griseofulvin, microsize ORAL SUSP 125 mg/5 mL N Y PA Document
69097036108 GRISEOFULVIN griseofulvin, microsize ORAL SUSP 125 mg/5 mL N Y PA Document
00781551501 GRISEOFULVIN griseofulvin, microsize TABLET 500 mg N Y PA Document
23155086501 GRISEOFULVIN griseofulvin, microsize TABLET 500 mg N Y PA Document
42794001208 GRISEOFULVIN griseofulvin, microsize TABLET 500 mg N Y PA Document
62135049601 GRISEOFULVIN griseofulvin, microsize TABLET 500 mg N Y PA Document
62135049630 GRISEOFULVIN griseofulvin, microsize TABLET 500 mg N Y PA Document
75788011504 BREXAFEMME ibrexafungerp citrate TABLET 150 mg N Y PA Document
00469052001 CRESEMBA isavuconazonium sulfate CAPSULE 186 mg N Y PA Document
00469052002 CRESEMBA isavuconazonium sulfate CAPSULE 186 mg N Y PA Document
00469286001 CRESEMBA isavuconazonium sulfate CAPSULE 74.5 mg N Y PA Document
00469286035 CRESEMBA isavuconazonium sulfate CAPSULE 74.5 mg N Y PA Document
51862046260 TOLSURA itraconazole CAP SD DSP 65 mg N Y PA Document
10147170003 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
13668046330 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
16571024503 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
16714074302 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
49884023911 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
50268045011 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
50268045012 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
60687029925 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
60687029995 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
62332020404 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
62332020430 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
65162063003 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
67877045430 ITRACONAZOLE itraconazole CAPSULE 100 mg N Y PA Document
50458029001 SPORANOX itraconazole CAPSULE 100 mg N Y PA Document
50458029004 SPORANOX itraconazole CAPSULE 100 mg N Y PA Document
31722000631 ITRACONAZOLE itraconazole SOLUTION 10 mg/mL N Y PA Document
65162008774 ITRACONAZOLE itraconazole SOLUTION 10 mg/mL N Y PA Document
69339015901 ITRACONAZOLE itraconazole SOLUTION 10 mg/mL N Y PA Document
69339015917 ITRACONAZOLE itraconazole SOLUTION 10 mg/mL N Y PA Document
35573043302 KETOCONAZOLE ketoconazole TABLET 200 mg N Y PA Document
35573043330 KETOCONAZOLE ketoconazole TABLET 200 mg N Y PA Document
51672402601 KETOCONAZOLE ketoconazole TABLET 200 mg N Y PA Document
51672402606 KETOCONAZOLE ketoconazole TABLET 200 mg N Y PA Document
64380082706 KETOCONAZOLE ketoconazole TABLET 200 mg N Y PA Document
69292022401 KETOCONAZOLE ketoconazole TABLET 200 mg N Y PA Document
61825030314 ORAVIG miconazole MA BUC TAB 50 mg N Y PA Document
00003058860 MYCOSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00054860716 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00121086800 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00121086802 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00121086805 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00121086816 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00121086850 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00121104516 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00168003703 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00603148049 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00904727641 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00904727670 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00904727692 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
60687080017 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
60687080040 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
62135081305 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
62135081324 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
62135081346 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
62135081347 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
63739016010 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
63739016056 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
63739016070 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
69315050447 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
69315050460 NYSTATIN nystatin ORAL SUSP 100,000 unit/mL Y Y  
00093098301 NYSTATIN nystatin TABLET 500,000 unit Y Y  
23155005101 NYSTATIN nystatin TABLET 500,000 unit Y Y  
53489040001 NYSTATIN nystatin TABLET 500,000 unit Y Y  
62135074190 NYSTATIN nystatin TABLET 500,000 unit Y Y  
74695082318 VIVJOA oteseconazole CAPSULE 150 mg N Y PA Document
00085132801 NOXAFIL posaconazole ORAL SUSP 200 mg/5 mL (40 mg/mL) N Y PA Document
00054044949 POSACONAZOLE posaconazole ORAL SUSP 200 mg/5 mL (40 mg/mL) N Y PA Document
00254101636 POSACONAZOLE posaconazole ORAL SUSP 200 mg/5 mL (40 mg/mL) N Y PA Document
00085222401 NOXAFIL posaconazole SUSPDR PKT 300 mg N Y PA Document
00085222402 NOXAFIL posaconazole SUSPDR PKT 300 mg N Y PA Document
00085432402 NOXAFIL posaconazole TABLET DR 100 mg N Y PA Document
00254204502 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
00406771160 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
00527213335 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
00904714904 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
00904714910 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
16714053501 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
31722067760 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
43598047060 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
50268068311 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
50268068312 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
59651059660 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
60687052311 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
60687052321 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
60687052394 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
62135042960 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
69238147606 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
69367024806 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
70377003811 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
70748025807 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
72205016860 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
72319002302 POSACONAZOLE posaconazole TABLET DR 100 mg N Y PA Document
16714079501 TERBINAFINE HCL terbinafine HCl TABLET 250 mg N Y PA Document
16714079502 TERBINAFINE HCL terbinafine HCl TABLET 250 mg N Y PA Document
51991052601 TERBINAFINE HCL terbinafine HCl TABLET 250 mg N Y PA Document
51991052633 TERBINAFINE HCL terbinafine HCl TABLET 250 mg N Y PA Document
62135057230 TERBINAFINE HCL terbinafine HCl TABLET 250 mg N Y PA Document
62135057290 TERBINAFINE HCL terbinafine HCl TABLET 250 mg N Y PA Document
65862007930 TERBINAFINE HCL terbinafine HCl TABLET 250 mg N Y PA Document
69097085902 TERBINAFINE HCL terbinafine HCl TABLET 250 mg N Y PA Document
69097085907 TERBINAFINE HCL terbinafine HCl TABLET 250 mg N Y PA Document
69452035113 TERBINAFINE HCL terbinafine HCl TABLET 250 mg N Y PA Document
69452035120 TERBINAFINE HCL terbinafine HCl TABLET 250 mg N Y PA Document
00049316044 VFEND voriconazole SUSP RECON 200 mg/5 mL (40 mg/mL) N Y PA Document
43386003860 VORICONAZOLE voriconazole SUSP RECON 200 mg/5 mL (40 mg/mL) N Y PA Document
59762093503 VORICONAZOLE voriconazole SUSP RECON 200 mg/5 mL (40 mg/mL) N Y PA Document
65162091322 VORICONAZOLE voriconazole SUSP RECON 200 mg/5 mL (40 mg/mL) N Y PA Document
70436023039 VORICONAZOLE voriconazole SUSP RECON 200 mg/5 mL (40 mg/mL) N Y PA Document
00049318030 VFEND voriconazole TABLET 200 mg N Y PA Document
00781566831 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
00904702404 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
16714019901 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
27241006303 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
43547037803 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
50268080311 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
50268080312 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
51079016501 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
51079016503 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
60687027311 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
60687027321 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
63739000833 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
65862089230 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
68462057330 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
72578006306 VORICONAZOLE voriconazole TABLET 200 mg N Y PA Document
00049317030 VFEND voriconazole TABLET 50 mg N Y PA Document
00781566731 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
00904659604 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
16714019801 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
27241006203 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
43547037703 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
51079016401 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
51079016403 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
60687029411 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
60687029421 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
65862089130 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
68462057230 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
72578006206 VORICONAZOLE voriconazole TABLET 50 mg N Y PA Document
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