Actinic Keratosis
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 |
|---|---|---|---|---|---|---|---|
| 70621010101 | AMELUZ | aminolevulinic acid HCl | GEL (GRAM) | 10 % | N | Y | PA Document |
| 70621010110 | AMELUZ | aminolevulinic acid HCl | GEL (GRAM) | 10 % | N | Y | PA Document |
| 70621010120 | AMELUZ | aminolevulinic acid HCl | GEL (GRAM) | 10 % | N | Y | PA Document |
| 70621010130 | AMELUZ | aminolevulinic acid HCl | GEL (GRAM) | 10 % | N | Y | PA Document |
| 67308010101 | LEVULAN | aminolevulinic acid HCl | SOL W/APPL | 20 % | N | Y | PA Document |
| 67308010106 | LEVULAN | aminolevulinic acid HCl | SOL W/APPL | 20 % | N | Y | PA Document |
| 50090725000 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 57896014001 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 57896014701 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 58602060407 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 62379040101 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 63868073001 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 63981087005 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 69842072902 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 69842097417 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 69842097435 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 69842097453 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 71205067000 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 71205074700 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 81877072310 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | N | |
| 00536129434 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 00536129497 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 21922000909 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 21922004409 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 43598097710 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 45802095301 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 46122075237 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 46122075252 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 46122075253 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 68001062145 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 69097052444 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 69097072044 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 69238205301 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 70512010610 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 76282010339 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 76282066339 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 82429031410 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 83324030601 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 1 % | Y | Y | |
| 00472178310 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 3 % | N | Y | PA Document |
| 45802011101 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 3 % | N | Y | PA Document |
| 45861006301 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 3 % | N | Y | PA Document |
| 51672136307 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 3 % | N | Y | PA Document |
| 62332058131 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 3 % | N | Y | PA Document |
| 68462035594 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 3 % | N | Y | PA Document |
| 71085000300 | DICLOFENAC SODIUM | diclofenac sodium | GEL (GRAM) | 3 % | N | Y | PA Document |
| 00378807849 | FLUOROURACIL | fluorouracil | CREAM (G) | 0.5 % | N | Y | PA Document |
| 75907016911 | FLUOROURACIL | fluorouracil | CREAM (G) | 0.5 % | N | Y | PA Document |
| 00187320447 | EFUDEX | fluorouracil | CREAM (G) | 5 % | Y | Y | |
| 00378479106 | FLUOROURACIL | fluorouracil | CREAM (G) | 5 % | Y | Y | |
| 16714017801 | FLUOROURACIL | fluorouracil | CREAM (G) | 5 % | Y | Y | |
| 16729054235 | FLUOROURACIL | fluorouracil | CREAM (G) | 5 % | Y | Y | |
| 21922004917 | FLUOROURACIL | fluorouracil | CREAM (G) | 5 % | Y | Y | |
| 51672411806 | FLUOROURACIL | fluorouracil | CREAM (G) | 5 % | Y | Y | |
| 51862036240 | FLUOROURACIL | fluorouracil | CREAM (G) | 5 % | Y | Y | |
| 75907009540 | FLUOROURACIL | fluorouracil | CREAM (G) | 5 % | Y | Y | |
| 51672406201 | FLUOROURACIL | fluorouracil | SOLUTION | 2 % | N | Y | PA Document |
| 21922004112 | FLUOROURACIL | fluorouracil | SOLUTION | 5 % | N | Y | PA Document |
| 51672406301 | FLUOROURACIL | fluorouracil | SOLUTION | 5 % | N | Y | PA Document |
| 51672417406 | IMIQUIMOD | imiquimod | CREAM PACK | 3.75 % | N | Y | PA Document |
| 99207027028 | ZYCLARA | imiquimod | CREAM PACK | 3.75 % | N | Y | PA Document |
| 00115147659 | IMIQUIMOD | imiquimod | CREAM PACK | 5 % | Y | Y | |
| 45802036800 | IMIQUIMOD | imiquimod | CREAM PACK | 5 % | Y | Y | |
| 45802036853 | IMIQUIMOD | imiquimod | CREAM PACK | 5 % | Y | Y | |
| 45802036862 | IMIQUIMOD | imiquimod | CREAM PACK | 5 % | Y | Y | |
| 51672414506 | IMIQUIMOD | imiquimod | CREAM PACK | 5 % | Y | Y | |
| 51672414508 | IMIQUIMOD | imiquimod | CREAM PACK | 5 % | Y | Y | |
| 64380077300 | IMIQUIMOD | imiquimod | CREAM PACK | 5 % | Y | Y | |
| 68462053670 | IMIQUIMOD | imiquimod | CREAM PACK | 5 % | Y | Y | |
| 99207027675 | ZYCLARA | imiquimod | CRM MD PMP | 2.5 % | N | Y | PA Document |
| 00093313331 | IMIQUIMOD | imiquimod | CRM MD PMP | 3.75 % | N | Y | PA Document |
| 51672417409 | IMIQUIMOD | imiquimod | CRM MD PMP | 3.75 % | N | Y | PA Document |
| 68682027275 | IMIQUIMOD | imiquimod | CRM MD PMP | 3.75 % | N | Y | PA Document |
| 99207027175 | ZYCLARA | imiquimod | CRM MD PMP | 3.75 % | N | Y | PA Document |