Glaucoma Drugs

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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
BETAXOLOL HCL BETAXOLOL HCL DROPS Y    
BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE DROPS Y    
BRIMONIDINE TARTRATE ALPHAGAN P DROPS Y 0.1 % Require PA  
BRINZOLAMIDE AZOPT DROPS SUSP Y    
CARTEOLOL HCL CARTEOLOL HCL DROPS Y    
DORZOLAMIDE HCL/TIMOLOL MALEAT COSOPT DROPS Y    
DORZOLAMIDE HCL/TIMOLOL MALEAT DORZOLAMIDE-TIMOLOL DROPS Y    
DORZOLAMIDE/TIMOLOL/PF COSOPT PF DROPERETTE Y    
LATANOPROST LATANOPROST DROPS Y    
LATANOPROST XALATAN DROPS Y    
PILOCARPINE HCL PILOCARPINE HCL DROPS Y    
PILOCARPINE HCL ISOPTO CARPINE DROPS Y    
TIMOLOL MALEATE TIMOLOL MALEATE DROPS Y    
TIMOLOL MALEATE TIMOPTIC DROPS Y    
TRAVOPROST TRAVATAN Z DROPS Y    
ACETYLCHOLINE CHLORIDE MIOCHOL-E KIT N    
APRACLONIDINE HCL IOPIDINE DROPERETTE N    
APRACLONIDINE HCL IOPIDINE DROPS N    
APRACLONIDINE HCL APRACLONIDINE HCL DROPS N    
BETAXOLOL HCL BETOPTIC S DROPS SUSP N    
BIMATOPROST LUMIGAN DROPS N    
BIMATOPROST BIMATOPROST DROPS N    
BRIMONIDINE TARTRATE/TIMOLOL COMBIGAN DROPS N    
BRINZOLAMIDE/BRIMONIDINE TART SIMBRINZA DROPS SUSP N    
CARBACHOL MIOSTAT VIAL N    
DORZOLAMIDE HCL TRUSOPT DROPS N    
DORZOLAMIDE HCL DORZOLAMIDE HCL DROPS N    
ECHOTHIOPHATE IODIDE PHOSPHOLINE IODIDE DROPS N    
LEVOBUNOLOL HCL LEVOBUNOLOL HCL DROPS N    
LEVOBUNOLOL HCL BETAGAN DROPS N    
TAFLUPROST/PF ZIOPTAN DROPERETTE N    
TIMOLOL MALEATE ISTALOL DROP DAILY N    
TIMOLOL MALEATE TIMOPTIC-XE SOL-GEL N    
TIMOLOL MALEATE TIMOLOL MALEATE SOL-GEL N    
TIMOLOL MALEATE/PF TIMOPTIC OCUDOSE DROPERETTE N