Antiparasitics, Topical
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 00682005110 | CROTAN | crotamiton | LOTION | 10 % | N | Y | |
| 00682005120 | CROTAN | crotamiton | LOTION | 10 % | N | Y | |
| 00682005130 | CROTAN | crotamiton | LOTION | 10 % | N | Y | |
| 73352005110 | PRURADIK | crotamiton | LOTION | 10 % | N | Y | |
| 51672423008 | IVERMECTIN | ivermectin | LOTION | 0.5 % | N | Y | |
| 24338018504 | SKLICE | ivermectin | LOTION | 0.5 % | N | Y | |
| 51672529404 | MALATHION | malathion | LOTION | 0.5 % | N | Y | |
| 63736024797 | NIX COMPLETE | permethrin | COMBO. PKG | 1 %-0.25 % | Y | N | |
| 59651083460 | ELIMITE | permethrin | CREAM (G) | 5 % | Y | Y | |
| 00472024260 | PERMETHRIN | permethrin | CREAM (G) | 5 % | Y | Y | |
| 16714089701 | PERMETHRIN | permethrin | CREAM (G) | 5 % | Y | Y | |
| 21922002107 | PERMETHRIN | permethrin | CREAM (G) | 5 % | Y | Y | |
| 45802026937 | PERMETHRIN | permethrin | CREAM (G) | 5 % | Y | Y | |
| 10939055833 | LICE KILLING | permethrin | LIQUID | 1 % | Y | N | |
| 00113191016 | LICE KILLING | permethrin | LIQUID | 1 % | Y | Y | |
| 49348043437 | LICE KILLING | permethrin | LIQUID | 1 % | Y | Y | |
| 00363095526 | LICE TREATMENT | permethrin | LIQUID | 1 % | Y | N | |
| 10939073944 | LICE TREATMENT | permethrin | LIQUID | 1 % | Y | N | |
| 11822985580 | LICE TREATMENT | permethrin | LIQUID | 1 % | Y | N | |
| 49022014067 | LICE TREATMENT | permethrin | LIQUID | 1 % | Y | N | |
| 49022050752 | LICE TREATMENT | permethrin | LIQUID | 1 % | Y | N | |
| 50428029260 | LICE TREATMENT | permethrin | LIQUID | 1 % | Y | N | |
| 52569013892 | LICE TREATMENT | permethrin | LIQUID | 1 % | Y | N | |
| 59779076926 | LICE TREATMENT | permethrin | LIQUID | 1 % | Y | N | |
| 87701041115 | LICE TREATMENT | permethrin | LIQUID | 1 % | Y | N | |
| 46122010846 | LICE TREATMENT | permethrin | LIQUID | 1 % | Y | Y | |
| 00501078202 | NIX | permethrin | LIQUID | 1 % | Y | N | |
| 00501078214 | NIX | permethrin | LIQUID | 1 % | Y | N | |
| 63736012002 | NIX | permethrin | LIQUID | 1 % | Y | N | |
| 63736012003 | NIX | permethrin | LIQUID | 1 % | Y | N | |
| 82468095085 | PERMETHRIN | permethrin | LIQUID | 1 % | Y | N | |
| 82468095086 | PERMETHRIN | permethrin | LIQUID | 1 % | Y | N | |
| 87701000172 | PERMETHRIN | permethrin | LIQUID | 1 % | Y | N | |
| 87701098492 | PERMETHRIN | permethrin | LIQUID | 1 % | Y | N | |
| 24385022126 | PERMETHRIN | permethrin | LIQUID | 1 % | Y | Y | |
| 00363010162 | COMPLETE LICE TREATMENT | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 49022037696 | COMPLETE LICE TREATMENT | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 70030014860 | COMPLETE LICE TREATMENT | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 81131073209 | COMPLETE LICE TREATMENT | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 30142017362 | LICE COMPLETE KIT 1-2-3 | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 10939055533 | LICE SOLUTION | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 11822031525 | LICE SOLUTION | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 50428026726 | LICE SOLUTION | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 50428042232 | LICE SOLUTION | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 87701009421 | LICE SOLUTION | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 00280902509 | RID | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 16500050492 | RID | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 16500052990 | RID | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 74300000820 | RID | piperonyl but/pyrethins/permet | KIT | 4 %-0.33 %-0.5 % | Y | N | |
| 58573900001 | INNOGEL PLUS | piperonyl butoxide/pyrethrins | GEL (GRAM) | 3 %-0.3 % | Y | N | |
| 00927004530 | TISIT | piperonyl butoxide/pyrethrins | GEL (GRAM) | 3 %-0.3 % | Y | N | |
| 58809065008 | VANALICE | piperonyl butoxide/pyrethrins | GEL (ML) | 3.5 %-0.3 % | N | Y | |
| 87701056903 | LICE TREATMENT | piperonyl butoxide/pyrethrins | KIT | Y | N | ||
| 00927023553 | TISIT | piperonyl butoxide/pyrethrins | KIT | Y | N | ||
| 10310022524 | PRONTO | piperonyl butoxide/pyrethrins | KIT | 4 %-0.33 % | Y | N | |
| 87701089300 | PYRETHRIN LICE TREATMENT | piperonyl butoxide/pyrethrins | LIQUID | Y | N | ||
| 00927014712 | TISIT | piperonyl butoxide/pyrethrins | LIQUID | 2 %-0.3 % | Y | N | |
| 00927014739 | TISIT | piperonyl butoxide/pyrethrins | LIQUID | 2 %-0.3 % | Y | N | |
| 87701059709 | LICE CREME RINSE | piperonyl butoxide/pyrethrins | LIQUID | 4 %-0.33 % | Y | N | |
| 12810024306 | LICE TREATMENT | piperonyl butoxide/pyrethrins | LIQUID | 4 %-0.33 % | Y | N | |
| 12810024331 | LICE TREATMENT | piperonyl butoxide/pyrethrins | LIQUID | 4 %-0.33 % | Y | N | |
| 54807055604 | PIOJINA II | piperonyl butoxide/pyrethrins | LIQUID | 4 %-0.33 % | Y | N | |
| 64899053842 | PYRETHRIN | piperonyl butoxide/pyrethrins | LIQUID | 4 %-0.33 % | Y | N | |
| 87701053376 | LICE TREATMENT | piperonyl butoxide/pyrethrins | SHAMPOO | 3 %-0.3 % | Y | N | |
| 52297011626 | MEDI-LICE | piperonyl butoxide/pyrethrins | SHAMPOO | 3 %-0.3 % | Y | N | |
| 12810020604 | LICE ELIMINATION | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 12810020606 | LICE ELIMINATION | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 00363086626 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 00363086634 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 10939055633 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 30142086634 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 35515095399 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 36800086634 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 41163024480 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 41163086634 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 49022037358 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 49022037359 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 49035086630 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 50428042075 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 50428178608 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 50804025304 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 52569013505 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 70030014843 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 81131073212 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 00904734920 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | Y | |
| 46122075929 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | Y | |
| 70677118401 | LICE KILLING | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | Y | |
| 11822989180 | LICE PYRINYL SHAMPOO | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 87701053380 | LICE TREATMENT | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 10960072604 | LICETROL | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 49614053326 | MEDI-LICE | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 10310023002 | PRONTO | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 10310023004 | PRONTO | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 10310036502 | PRONTO | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 10310036504 | PRONTO | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 00280900002 | RID | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 00280900008 | RID | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 00280903006 | RID | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 16500054256 | RID | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 74300000320 | RID | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 74300000412 | RID | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 74300000414 | RID | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 74300001181 | RID | piperonyl butoxide/pyrethrins | SHAMPOO | 4 %-0.33 % | Y | N | |
| 52246092904 | NATROBA | spinosad | SUSPENSION | 0.9 % | N | Y | |
| 28595057004 | SPINOSAD | spinosad | SUSPENSION | 0.9 % | N | Y | |
| 52246057004 | SPINOSAD | spinosad | SUSPENSION | 0.9 % | N | Y | |
| 45802009603 | SULFUR | sulfur | OINT. (G) | 2 % | N | Y | |
| 45802009605 | SULFUR | sulfur | OINT. (G) | 2 % | N | Y |