Antibiotics, Ophthalmic

← Back to Class List

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 CILOXAN DROPS Y    
ciprofloxacin HCl CIPROFLOXACIN HCL 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    
moxifloxacin HCl MOXIFLOXACIN 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 POLYMYXIN B SUL-TRIMETHOPRIM DROPS Y    
polymyxin B sulf/trimethoprim POLYTRIM DROPS Y    
sulfacetamide sodium BLEPH-10 DROPS Y    
sulfacetamide sodium SULFACETAMIDE SODIUM 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 NEOMYCIN-BACITRACIN-POLYMYXIN OINT. (G) N    
neomycin sulf/bacitracin/poly NEO-POLYCIN OINT. (G) N    
sulfacetamide sodium SULFACETAMIDE SODIUM OINT. (G) N