Antibiotics, 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
BACITRACIN BACITRACIN OINT. (G) Y 500 unit/gram Require PA  
BACITRACIN/POLYMYXIN B SULFATE POLYCIN OINT. (G) Y    
BACITRACIN/POLYMYXIN B SULFATE BACITRACIN-POLYMYXIN OINT. (G) Y    
CIPROFLOXACIN HCL CIPROFLOXACIN HCL DROPS Y    
CIPROFLOXACIN HCL CILOXAN DROPS Y    
CIPROFLOXACIN HCL CILOXAN OINT. (G) Y    
ERYTHROMYCIN BASE ERYTHROMYCIN OINT. (G) Y    
GENTAMICIN SULFATE GENTAMICIN SULFATE DROPS Y    
GENTAMICIN SULFATE GENTAK OINT. (G) Y    
MOXIFLOXACIN HCL VIGAMOX DROPS Y    
NATAMYCIN NATACYN DROPS SUSP Y    
NEOMYCIN/POLYMYXN B/GRAMICIDIN NEOMYCIN-POLYMYXIN-GRAMICIDIN DROPS Y    
OFLOXACIN OCUFLOX DROPS Y    
OFLOXACIN OFLOXACIN DROPS Y    
POLYMYXIN B SULF/TRIMETHOPRIM POLYTRIM DROPS Y    
POLYMYXIN B SULF/TRIMETHOPRIM POLYMYXIN B SUL-TRIMETHOPRIM DROPS Y    
SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM DROPS Y    
SULFACETAMIDE SODIUM BLEPH-10 DROPS Y    
TOBRAMYCIN TOBREX DROPS Y    
TOBRAMYCIN TOBRAMYCIN DROPS Y    
TOBRAMYCIN TOBREX OINT. (G) Y    
AZITHROMYCIN AZASITE DROPS N    
BESIFLOXACIN HCL BESIVANCE DROPS SUSP N    
GATIFLOXACIN GATIFLOXACIN DROPS N    
GATIFLOXACIN ZYMAXID DROPS N    
LEVOFLOXACIN LEVOFLOXACIN DROPS N    
MOXIFLOXACIN HCL MOXEZA DROPS VISC N    
NEOMYCIN SULF/BACITRACIN/POLY NEO-POLYCIN OINT. (G) N    
NEOMYCIN SULF/BACITRACIN/POLY NEOMYCIN-BACITRACIN-POLYMYXIN OINT. (G) N    
SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM OINT. (G) N