Topical Products for Inflammatory Skin Diseases
PDL Reference Documents
- Topicals for Inflammatory Skin Conditions - Dec 01, 2022
- Therapeutics for Atopic Dermatitis and Inflammatory Skin Conditions - Jun 02, 2022
- Vitiligo Literature Scan - Jun 02, 2022
- Atopic Dermatitis - Oct 01, 2020
- Dupixent (dupilumab) Indication Update - Nov 21, 2019
- Atopic Dermatitis - Jul 25, 2019
- Atopic Dermatitis - Mar 22, 2018
- Topical Antipsoriatics Literature Scan - Sep 28, 2017
- Topical Psoriasis Literature Scan - Jan 29, 2015
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 |
|---|---|---|---|---|---|---|---|
| 64980031250 | ANTHRALIN | anthralin | CREAM (G) | 1 % | N | Y | Age Restriction |
| 16714076301 | CALCIPOTRIENE | calcipotriene | CREAM (G) | 0.005 % | Y | Y | Age Restriction |
| 16714076302 | CALCIPOTRIENE | calcipotriene | CREAM (G) | 0.005 % | Y | Y | Age Restriction |
| 66993087761 | CALCIPOTRIENE | calcipotriene | CREAM (G) | 0.005 % | Y | Y | Age Restriction |
| 66993087778 | CALCIPOTRIENE | calcipotriene | CREAM (G) | 0.005 % | Y | Y | Age Restriction |
| 68462050165 | CALCIPOTRIENE | calcipotriene | CREAM (G) | 0.005 % | Y | Y | Age Restriction |
| 68462050166 | CALCIPOTRIENE | calcipotriene | CREAM (G) | 0.005 % | Y | Y | Age Restriction |
| 51862051260 | CALCIPOTRIENE | calcipotriene | FOAM | 0.005 % | N | Y | Age Restriction |
| 51862037612 | SORILUX | calcipotriene | FOAM | 0.005 % | N | Y | Age Restriction |
| 51672415403 | CALCIPOTRIENE | calcipotriene | OINT. (G) | 0.005 % | N | Y | Age Restriction |
| 51672415404 | CALCIPOTRIENE | calcipotriene | OINT. (G) | 0.005 % | N | Y | Age Restriction |
| 66993087861 | CALCIPOTRIENE | calcipotriene | OINT. (G) | 0.005 % | N | Y | Age Restriction |
| 66993087878 | CALCIPOTRIENE | calcipotriene | OINT. (G) | 0.005 % | N | Y | Age Restriction |
| 68462031065 | CALCIPOTRIENE | calcipotriene | OINT. (G) | 0.005 % | N | Y | Age Restriction |
| 68462031066 | CALCIPOTRIENE | calcipotriene | OINT. (G) | 0.005 % | N | Y | Age Restriction |
| 50222030260 | ENSTILAR | calcipotriene/betamethasone | FOAM | 0.005 %-0.064 % | N | Y | Age Restriction |
| 50222030266 | ENSTILAR | calcipotriene/betamethasone | FOAM | 0.005 %-0.064 % | N | Y | Age Restriction |
| 45802081601 | CALCIPOTRIENE-BETAMETHASONE | calcipotriene/betamethasone | OINT. (G) | 0.005 %-0.064 % | Y | Y | Age Restriction |
| 45802081696 | CALCIPOTRIENE-BETAMETHASONE | calcipotriene/betamethasone | OINT. (G) | 0.005 %-0.064 % | Y | Y | Age Restriction |
| 66993093861 | CALCIPOTRIENE-BETAMETHASONE | calcipotriene/betamethasone | OINT. (G) | 0.005 %-0.064 % | Y | Y | Age Restriction |
| 66993093865 | CALCIPOTRIENE-BETAMETHASONE | calcipotriene/betamethasone | OINT. (G) | 0.005 %-0.064 % | Y | Y | Age Restriction |
| 00713084860 | CALCIPOTRIENE-BETAMETHASONE | calcipotriene/betamethasone | SUSPENSION | 0.005 %-0.064 % | N | Y | Age Restriction |
| 00713084892 | CALCIPOTRIENE-BETAMETHASONE | calcipotriene/betamethasone | SUSPENSION | 0.005 %-0.064 % | N | Y | Age Restriction |
| 51672140204 | CALCIPOTRIENE-BETAMETHASONE | calcipotriene/betamethasone | SUSPENSION | 0.005 %-0.064 % | N | Y | Age Restriction |
| 51672140208 | CALCIPOTRIENE-BETAMETHASONE | calcipotriene/betamethasone | SUSPENSION | 0.005 %-0.064 % | N | Y | Age Restriction |
| 63646004012 | CALCIPOTRIENE-BETAMETHASONE | calcipotriene/betamethasone | SUSPENSION | 0.005 %-0.064 % | N | Y | Age Restriction |
| 63646004060 | CALCIPOTRIENE-BETAMETHASONE | calcipotriene/betamethasone | SUSPENSION | 0.005 %-0.064 % | N | Y | Age Restriction |
| 50222050106 | TACLONEX | calcipotriene/betamethasone | SUSPENSION | 0.005 %-0.064 % | N | Y | Age Restriction |
| 50222050166 | TACLONEX | calcipotriene/betamethasone | SUSPENSION | 0.005 %-0.064 % | N | Y | Age Restriction |
| 45802060801 | CALCITRIOL | calcitriol | OINT. (G) | 3 mcg/gram | N | Y | Age Restriction |
| 68308066510 | CALCITRIOL | calcitriol | OINT. (G) | 3 mcg/gram | N | Y | Age Restriction |
| 00299201210 | VECTICAL | calcitriol | OINT. (G) | 3 mcg/gram | N | Y | Age Restriction |
| 00096073704 | DHS TAR | coal tar | SHAMPOO | 0.5 % | N | Y | Age Restriction |
| 00096073708 | DHS TAR | coal tar | SHAMPOO | 0.5 % | N | Y | Age Restriction |
| 00096073608 | DHS TAR GEL | coal tar | SHAMPOO | 0.5 % | N | Y | Age Restriction |
| 83324028608 | T-PLUS | coal tar | SHAMPOO | 0.5 % | N | Y | Age Restriction |
| 83324028616 | T-PLUS | coal tar | SHAMPOO | 0.5 % | N | Y | Age Restriction |
| 00904525944 | THERA-GEL | coal tar | SHAMPOO | 0.5 % | N | Y | Age Restriction |
| 55724021111 | EUCRISA | crisaborole | OINT. (G) | 2 % | N | Y | Age Restriction |
| 55724021121 | EUCRISA | crisaborole | OINT. (G) | 2 % | N | Y | Age Restriction |
| 50222028030 | ANZUPGO | delgocitinib | CREAM (G) | 2 % | N | Y | Age Restriction |
| 00187065301 | DUOBRII | halobetasol propion/tazarotene | LOTION | 0.01 %-0.045 % | N | Y | Age Restriction |
| 00187510001 | ELIDEL | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 00187510102 | ELIDEL | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 00187510203 | ELIDEL | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 00591294430 | PIMECROLIMUS | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 00591294460 | PIMECROLIMUS | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 00591294487 | PIMECROLIMUS | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 68462060935 | PIMECROLIMUS | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 68462060965 | PIMECROLIMUS | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 68462060994 | PIMECROLIMUS | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 68682011001 | PIMECROLIMUS | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 68682011102 | PIMECROLIMUS | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 68682011203 | PIMECROLIMUS | pimecrolimus | CREAM (G) | 1 % | Y | Y | Age Restriction |
| 80610011560 | ZORYVE | roflumilast | CREAM (G) | 0.15 % | N | Y | Age Restriction |
| 80610013060 | ZORYVE | roflumilast | CREAM (G) | 0.3 % | N | Y | Age Restriction |
| 80610043060 | ZORYVE | roflumilast | FOAM | 0.3 % | N | Y | Age Restriction |
| 50881000704 | OPZELURA | ruxolitinib phosphate | CREAM (G) | 1.5 % | N | Y | Age Restriction |
| 50881000705 | OPZELURA | ruxolitinib phosphate | CREAM (G) | 1.5 % | N | Y | Age Restriction |
| 73683010110 | HYFTOR | sirolimus | GEL (GRAM) | 0.2 % | Y | Age Restriction | |
| 00168041730 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 00168041760 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 00168041799 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 16729042101 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 16729042110 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 16729042112 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 45802039000 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 45802039001 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 45802039002 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 68462088135 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 68462088165 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 68462088194 | TACROLIMUS | tacrolimus | OINT. (G) | 0.03 % | Y | Y | Age Restriction |
| 00168041630 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 00168041660 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 00168041699 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 16729042201 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 16729042210 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 16729042212 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 21922001105 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 21922001107 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 21922001109 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 45802070000 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 45802070001 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 45802070002 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 68308070360 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 68462053435 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 68462053465 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 68462053494 | TACROLIMUS | tacrolimus | OINT. (G) | 0.1 % | Y | Y | Age Restriction |
| 81672505101 | VTAMA | tapinarof | CREAM (G) | 1 % | N | Y | Age Restriction |
| 00713076531 | TAZAROTENE | tazarotene | CREAM (G) | 0.05 % | Y | Y | Age Restriction |
| 00713076560 | TAZAROTENE | tazarotene | CREAM (G) | 0.05 % | Y | Y | Age Restriction |
| 45802070694 | TAZAROTENE | tazarotene | CREAM (G) | 0.05 % | Y | Y | Age Restriction |
| 45802070696 | TAZAROTENE | tazarotene | CREAM (G) | 0.05 % | Y | Y | Age Restriction |
| 51672137302 | TAZAROTENE | tazarotene | CREAM (G) | 0.1 % | Y | Y | Age Restriction |
| 51672137303 | TAZAROTENE | tazarotene | CREAM (G) | 0.1 % | Y | Y | Age Restriction |
| 68308074530 | TAZAROTENE | tazarotene | CREAM (G) | 0.1 % | Y | Y | Age Restriction |
| 51862029510 | FABIOR | tazarotene | FOAM | 0.1 % | N | Y | PA Document |
| 68308068550 | TAZAROTENE | tazarotene | FOAM | 0.1 % | N | Y | PA Document |
| 00713080531 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.05 % | N | Y | Age Restriction |
| 00713080599 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.05 % | N | Y | Age Restriction |
| 45802043601 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.05 % | N | Y | Age Restriction |
| 45802043694 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.05 % | N | Y | Age Restriction |
| 73473030910 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.05 % | N | Y | Age Restriction |
| 73473030930 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.05 % | N | Y | Age Restriction |
| 00713080431 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.1 % | N | Y | Age Restriction |
| 00713080499 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.1 % | N | Y | Age Restriction |
| 45802044201 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.1 % | N | Y | Age Restriction |
| 45802044294 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.1 % | N | Y | Age Restriction |
| 73473031010 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.1 % | N | Y | Age Restriction |
| 73473031030 | TAZAROTENE | tazarotene | GEL (GRAM) | 0.1 % | N | Y | Age Restriction |
| 00187209845 | ARAZLO | tazarotene | LOTION | 0.045 % | N | Y | PA Document |