Antifungals, Vaginal

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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
45802039601 GYNAZOLE 1 butoconazole nitrate CRM/PF APP 2 % N Y  
51672670701 VAGINAL 3-DAY clotrimazole COMBO. PKG 200 mg-1 % N Y  
10939004533 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y N  
11822328110 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y N  
34575052749 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y N  
35515099077 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y N  
50090061400 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y N  
50090152200 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y N  
50090737600 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y N  
63868025915 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y N  
51672200306 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y Y  
61269022041 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y Y  
61269022063 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y Y  
70677122801 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y Y  
70677126201 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y Y  
83324015415 CLOTRIMAZOLE clotrimazole CREAM/APPL 1 % Y Y  
49022008436 CLOTRIMAZOLE-7 clotrimazole CREAM/APPL 1 % Y N  
54868041801 GYNE-LOTRIMIN clotrimazole CREAM/APPL 1 % Y N  
16500002502 MYCELEX-7 clotrimazole CREAM/APPL 1 % Y N  
16500002507 MYCELEX-7 clotrimazole CREAM/APPL 1 % Y N  
16500002508 MYCELEX-7 clotrimazole CREAM/APPL 1 % Y N  
16500002509 MYCELEX-7 clotrimazole CREAM/APPL 1 % Y N  
87701045404 3 DAY VAGINAL clotrimazole CREAM/APPL 2 % Y N  
10939057833 3-DAY VAGINAL CREAM clotrimazole CREAM/APPL 2 % Y N  
49348037954 3-DAY VAGINAL CREAM clotrimazole CREAM/APPL 2 % Y Y  
51672206200 3-DAY VAGINAL CREAM clotrimazole CREAM/APPL 2 % Y Y  
82468061453 CLOTRIMAZOLE clotrimazole CREAM/APPL 2 % Y N  
11917003586 CLOTRIMAZOLE-3 clotrimazole CREAM/APPL 2 % Y N  
11917007847 CLOTRIMAZOLE-3 clotrimazole CREAM/APPL 2 % Y N  
59779006200 CLOTRIMAZOLE-3 clotrimazole CREAM/APPL 2 % Y N  
87701045401 CLOTRIMAZOLE-3 clotrimazole CREAM/APPL 2 % Y N  
24385011009 CLOTRIMAZOLE-3 clotrimazole CREAM/APPL 2 % Y Y  
70677123101 CLOTRIMAZOLE-3 clotrimazole CREAM/APPL 2 % Y Y  
49348079436 CLOTRIMAZOLE clotrimazole TABLET 100 mg Y Y  
54868041702 GYNE-LOTRIMIN clotrimazole TABLET 100 mg Y N  
16500002501 MYCELEX-7 clotrimazole TABLET 100 mg Y N  
16500002505 MYCELEX-7 clotrimazole TABLET 100 mg Y N  
54868108600 MYCELEX-7 clotrimazole TABLET 100 mg Y N  
11822032300 MICONAZOLE 3 miconazole nitrate CMB PF CRM 4 % (200 mg)-2 % (9 gram) Y N  
30142098200 MICONAZOLE 3 miconazole nitrate CMB PF CRM 4 % (200 mg)-2 % (9 gram) Y N  
36800098200 MICONAZOLE 3 miconazole nitrate CMB PF CRM 4 % (200 mg)-2 % (9 gram) Y N  
50428039470 MICONAZOLE 3 miconazole nitrate CMB PF CRM 4 % (200 mg)-2 % (9 gram) Y N  
59779083900 MICONAZOLE 3 miconazole nitrate CMB PF CRM 4 % (200 mg)-2 % (9 gram) Y N  
00536142541 MICONAZOLE 3 miconazole nitrate CMB PF CRM 4 % (200 mg)-2 % (9 gram) Y Y  
70677122301 MICONAZOLE 3 miconazole nitrate CMB PF CRM 4 % (200 mg)-2 % (9 gram) Y Y  
63736000075 MONISTAT 3 miconazole nitrate CMB PF CRM 4 % (200 mg)-2 % (9 gram) Y N  
63736044300 MONISTAT 3 miconazole nitrate CMB PF CRM 4 % (200 mg)-2 % (9 gram) Y N  
10939037933 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
10960071686 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
11673082529 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
11822382270 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
30142082529 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
36800082529 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
41163025650 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
41163082529 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
49022008444 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
49035082529 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
50428038300 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
59779073041 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
70030013252 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
70030013422 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
81131073153 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
87701079251 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y N  
00113021429 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y Y  
00113082529 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y Y  
00904773445 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y Y  
24385059029 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y Y  
49348053077 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y Y  
61269073041 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y Y  
61269073063 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y Y  
70677122201 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y Y  
70677122501 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y Y  
83324016015 MICONAZOLE 7 miconazole nitrate CREAM/APPL 2 % Y Y  
10939038033 MICONAZOLE NITRATE miconazole nitrate CREAM/APPL 2 % Y N  
49035073007 MICONAZOLE NITRATE miconazole nitrate CREAM/APPL 2 % Y N  
81131002418 MICONAZOLE NITRATE miconazole nitrate CREAM/APPL 2 % Y N  
49348087277 MICONAZOLE NITRATE miconazole nitrate CREAM/APPL 2 % Y Y  
51672203506 MICONAZOLE NITRATE miconazole nitrate CREAM/APPL 2 % Y Y  
63868019845 MICONAZOLE-7 miconazole nitrate CREAM/APPL 2 % Y N  
70000000901 MICONAZOLE-7 miconazole nitrate CREAM/APPL 2 % Y Y  
63736010904 MONISTAT 7 miconazole nitrate CREAM/APPL 2 % Y N  
63736044263 MONISTAT 7 miconazole nitrate CREAM/APPL 2 % Y N  
00132060315 YEAST-X miconazole nitrate CREAM/APPL 2 % Y Y  
63736044201 MONISTAT 3 miconazole nitrate CRM/PF APP 200 mg/5 gram (4 %) Y N  
46122057702 MICONAZOLE 1 miconazole nitrate KIT 1,200 mg-2 % N Y  
00113008100 MICONAZOLE 3 miconazole nitrate KIT 200 mg-2 % (9 gram) N Y  
24385060602 MICONAZOLE 3 miconazole nitrate KIT 200 mg-2 % (9 gram) N Y  
49348035543 MICONAZOLE 3 miconazole nitrate KIT 200 mg-2 % (9 gram) N Y  
70677122601 MICONAZOLE 3 miconazole nitrate KIT 200 mg-2 % (9 gram) N Y  
00713059377 MICONAZOLE NITRATE miconazole nitrate KIT 200 mg-2 % (9 gram) N Y  
10939004633 MICONAZOLE 7 miconazole nitrate SUPP.VAG 100 mg Y N  
61269073607 MICONAZOLE 7 miconazole nitrate SUPP.VAG 100 mg Y Y  
37205012712 MICONAZOLE NITRATE miconazole nitrate SUPP.VAG 100 mg Y Y  
54868043401 MONISTAT 7 miconazole nitrate SUPP.VAG 100 mg Y N  
00472173803 MICONAZOLE 3 miconazole nitrate SUPP.VAG 200 mg N Y  
00132000612 YEAST-X pulsatilla SUPP.VAG Y  
00168034646 TERCONAZOLE terconazole CREAM/APPL 0.4 % Y Y  
51672130406 TERCONAZOLE terconazole CREAM/APPL 0.4 % Y Y  
00168034720 TERCONAZOLE terconazole CREAM/APPL 0.8 % Y Y  
51672130200 TERCONAZOLE terconazole CREAM/APPL 0.8 % Y Y  
45802071700 TERCONAZOLE terconazole SUPP.VAG 80 mg N Y  
45802071708 TERCONAZOLE terconazole SUPP.VAG 80 mg N Y  
63736044101 1-DAY tioconazole OIN/PF APP 6.5 % Y N  
63736000082 MONISTAT 1 tioconazole OIN/PF APP 6.5 % Y N  
36800042654 TIOCONAZOLE 1 tioconazole OIN/PF APP 6.5 % Y N  
87701034279 TIOCONAZOLE 1 tioconazole OIN/PF APP 6.5 % Y N  
00363033082 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y N  
00363042654 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y N  
10939048433 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y N  
11822360510 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y N  
11917005202 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y N  
11917005829 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y N  
41163003254 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y N  
59779071826 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y N  
81131069984 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y N  
87701034280 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y N  
96295013372 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y N  
00113042654 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y Y  
70000035701 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y Y  
70677122401 TIOCONAZOLE-1 tioconazole OIN/PF APP 6.5 % Y Y  
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