Antibiotic-Steroids, 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
GENTAMICIN SULF/PREDNISOLONE PRED-G DROPS SUSP Y    
GENTAMICIN SULF/PREDNISOLONE PRED-G OINT. (G) Y    
NEOMYCIN/POLYMYXIN B/DEXAMETHA MAXITROL DROPS SUSP Y    
NEOMYCIN/POLYMYXIN B/DEXAMETHA NEOMYCIN-POLYMYXIN-DEXAMETH DROPS SUSP Y    
NEOMYCIN/POLYMYXIN B/DEXAMETHA NEOMYCIN-POLYMYXIN-DEXAMETH OINT. (G) Y    
NEOMYCIN/POLYMYXIN B/DEXAMETHA MAXITROL OINT. (G) Y    
NEOMYCIN/POLYMYXIN B/HYDROCORT NEOMYCIN-POLYMYXIN-HC DROPS SUSP Y 3.5 mg-10,000 unit-10 mg/mL Require PA  
SULFACETAMIDE/PREDNISOLONE BLEPHAMIDE DROPS SUSP Y    
SULFACETAMIDE/PREDNISOLONE BLEPHAMIDE S.O.P. OINT. (G) Y    
TOBRAMYCIN/DEXAMETHASONE TOBRADEX DROPS SUSP Y    
TOBRAMYCIN/DEXAMETHASONE TOBRADEX ST DROPS SUSP Y    
TOBRAMYCIN/DEXAMETHASONE TOBRAMYCIN-DEXAMETHASONE DROPS SUSP Y    
TOBRAMYCIN/DEXAMETHASONE TOBRADEX OINT. (G) Y    
NEOMYCIN/BACIT/P-MYX/HYDROCORT NEOMYCIN-BACITRACIN-POLY-HC OINT. (G) N    
NEOMYCIN/BACIT/P-MYX/HYDROCORT NEO-POLYCIN HC OINT. (G) N    
SULFACETAMIDE/PREDNISOLONE SP SULFACETAMIDE-PREDNISOLONE DROPS N    
TOBRAMYCIN/LOTEPRED ETAB ZYLET DROPS SUSP N