Anti-Inflammatory Drugs, Ophthalmic

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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 but eligible patients will encounter a co-pay at the pharmacy.
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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
DEXAMETHASONE MAXIDEX DROPS SUSP Y    
DEXAMETHASONE SOD PHOSPHATE DEXAMETHASONE SODIUM PHOSPHATE DROPS Y    
DICLOFENAC SODIUM DICLOFENAC SODIUM DROPS Y 1.5 % Require PA  
FLUOROMETHOLONE FLUOROMETHOLONE DROPS SUSP Y    
FLUOROMETHOLONE FML DROPS SUSP Y    
FLUOROMETHOLONE FML S.O.P. OINT. (G) Y    
FLURBIPROFEN SODIUM FLURBIPROFEN SODIUM DROPS Y    
KETOROLAC TROMETHAMINE ACULAR LS DROPS Y    
KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE DROPS Y    
KETOROLAC TROMETHAMINE ACULAR DROPS Y    
LOTEPREDNOL ETABONATE LOTEMAX DROPS SUSP Y    
PREDNISOLONE ACETATE OMNIPRED DROPS SUSP Y    
PREDNISOLONE ACETATE PREDNISOLONE ACETATE DROPS SUSP Y    
PREDNISOLONE ACETATE PRED FORTE DROPS SUSP Y    
BROMFENAC SODIUM BROMSITE DROPS N    
BROMFENAC SODIUM BROMFENAC SODIUM DROPS N    
BROMFENAC SODIUM PROLENSA DROPS N    
DIFLUPREDNATE DUREZOL DROPS N    
FLUOROMETHOLONE FML FORTE DROPS SUSP N    
FLUOROMETHOLONE ACETATE FLAREX DROPS SUSP N    
KETOROLAC TROMETHAMINE/PF ACUVAIL DROPERETTE N    
LOTEPREDNOL ETABONATE LOTEMAX DROPS GEL N    
LOTEPREDNOL ETABONATE ALREX DROPS SUSP N    
LOTEPREDNOL ETABONATE LOTEMAX OINT. (G) N    
NEPAFENAC NEVANAC DROPS SUSP N    
NEPAFENAC ILEVRO DROPS SUSP N    
PREDNISOLONE ACETATE PRED MILD DROPS SUSP N    
PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SODIUM PHOSPHATE DROPS N