Misc Opthalmic Preparations

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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 OZURDEX IMPLANT N    
FLUOCINOLONE ACETONIDE RETISERT IMPLANT N   Jan 31, 2013
FLUOCINOLONE ACETONIDE ILUVIEN IMPLANT N    
TRIAMCINOLONE ACETONIDE/PF TRIESENCE VIAL N    
ATROPINE SULFATE ATROPINE SULFATE DROPS    
ATROPINE SULFATE ATROPINE SULFATE OINT. (G)    
BALANCED SALT IRRIG SOLN NO.1 BSS PLUS IRRIG SOLN    
BALANCED SALT IRRIG SOLN NO.2 BSS IRRIG SOLN    
BALANCED SALT IRRIG SOLN NO.2 BALANCED SALT IRRIG SOLN    
BALANCED SALT SOLN NON-SURG 3 EYE-STREAM IRRIG SOLN    
CARBOXYMETHYL/GLY/POLY80/PF REFRESH OPTIVE ADVANCED DROPERETTE    
CARBOXYMETHYL/GLY/POLY80/PF REFRESH OPTIVE MEGA-3 DROPERETTE    
CARBOXYMETHYL/GLYCERIN/POLY80 REFRESH OPTIVE ADVANCED DROPS    
CARBOXYMETHYLCELL/GLYCERIN/PF REFRESH OPTIVE SENSITIVE DROPERETTE    
CARBOXYMETHYLCELLULOS/GLYCERIN REFRESH OPTIVE DROPS    
CARBOXYMETHYLCELLULOS/GLYCERIN REFRESH OPTIVE DROPS GEL    
CARBOXYMETHYLCELLULOSE SODIUM REFRESH CELLUVISC DROPER GEL    
CARBOXYMETHYLCELLULOSE SODIUM REFRESH PLUS DROPERETTE    
CARBOXYMETHYLCELLULOSE SODIUM LUBRICATING PLUS DROPERETTE    
CARBOXYMETHYLCELLULOSE SODIUM REFRESH TEARS DROPS    
CARBOXYMETHYLCELLULOSE SODIUM REFRESH LIQUIGEL DRP LQ GEL    
CROMOLYN SODIUM CROMOLYN SODIUM DROPS    
CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL DROPS    
CYCLOPENTOLATE HCL CYCLOGYL DROPS    
CYCLOPENTOLATE/PHENYLEPHRINE CYCLOMYDRIL DROPS    
CYCLOSPORINE RESTASIS DROPERETTE    
CYCLOSPORINE RESTASIS MULTIDOSE DROPS    
CYSTEAMINE HCL CYSTARAN DROPS    
DEXTRAN 70/HYPROMELLOSE NATURE'S TEARS DROPS    
DEXTRAN 70/HYPROMELLOSE NATURAL BALANCE TEARS DROPS    
DEXTRAN 70/HYPROMELLOSE GENTEAL TEARS DROPS    
DEXTRAN 70/HYPROMELLOSE/PF GENTEAL TEARS DROPERETTE    
DEXTRAN 70/HYPROMELLOSE/PF BION TEARS DROPERETTE    
DEXTRAN/HYPROMELLOSE/GLYCERIN GENTEAL TEARS DROPS    
EYE LUBRICANT COMBINATION NO.1 FRESHKOTE DROPS    
GANCICLOVIR ZIRGAN GEL (GRAM)    
HYDROXYPROPYL CELLULOSE LACRISERT INSERT    
HYPROMELLOSE ISOPTO TEARS DROPS    
HYPROMELLOSE GENTEAL SEVERE GEL (GRAM)    
HYPROMELLOSE SYSTANE GEL GEL (GRAM)    
LIDOCAINE HCL/PF AKTEN GEL (ML)    
LIFITEGRAST XIIDRA DROPERETTE   Jan 26, 2017
LODOXAMIDE TROMETHAMINE ALOMIDE DROPS    
MINERAL OIL/PETROLATUM,WHITE LUBRICANT PM OINT. (G)    
MINERAL OIL/PETROLATUM,WHITE PURALUBE OINT. (G)    
MINERAL OIL/PETROLATUM,WHITE SYSTANE OINT. (G)    
MINERAL OIL/PETROLATUM,WHITE ARTIFICIAL TEARS OINT. (G)    
MINERAL OIL/PETROLATUM,WHITE LUBRIFRESH PM OINT. (G)    
MINERAL OIL/PETROLATUM,WHITE REFRESH LACRI-LUBE OINT. (G)    
MINERAL OIL/PETROLATUM,WHITE REFRESH P.M. OINT. (G)    
NAPHAZOLINE HCL/GLYCERIN REDNESS RELIEF DROPS    
NAPHAZOLINE HCL/GLYCERIN EYE DROPS REDNESS RELIEF DROPS    
NAPHAZOLINE HCL/PHENIRAMINE NAPHCON-A DROPS    
NEDOCROMIL SODIUM ALOCRIL DROPS    
PHENYLEPHRINE HCL PHENYLEPHRINE HCL DROPS    
PHENYLEPHRINE/KETOROLAC OMIDRIA VIAL    
POLYVINYL ALCOHOL ARTIFICIAL TEARS DROPS    
POLYVINYL ALCOHOL LIQUITEARS DROPS    
POLYVINYL ALCOHOL/POVIDONE ARTIFICIAL TEARS DROPS    
POLYVINYL ALCOHOL/POVIDONE/PF REFRESH CLASSIC DROPERETTE    
POVIDONE-IODINE BETADINE SOLUTION    
PROPARACAINE HCL PROPARACAINE HCL DROPS    
PROPYLENE GLYCOL SYSTANE BALANCE DROPS    
PROPYLENE GLYCOL/PEG 400 LUBRICANT EYE DROPS    
PROPYLENE GLYCOL/PEG 400 SYSTANE ULTRA DROPS    
PROPYLENE GLYCOL/PEG 400 LUBRICATING TEARS DROPS    
PROPYLENE GLYCOL/PEG 400 ULTRA LUBRICANT EYE DROPS    
PROPYLENE GLYCOL/PEG 400 SYSTANE DROPS    
PROPYLENE GLYCOL/PEG 400 SYSTANE GEL DROPS GEL    
PROPYLENE GLYCOL/PEG 400/PF LUBRICANT EYE DROPERETTE    
PROPYLENE GLYCOL/PEG 400/PF SYSTANE DROPERETTE    
SOD BORATE/BORIC AC/WATER/NACL EYE IRRIGATING SOLUTION IRRIG SOLN    
SOD BORATE/BORIC AC/WATER/NACL EYE WASH IRRIG SOLN    
SODIUM CHLORIDE SODIUM CHLORIDE DROPS    
SODIUM CHLORIDE MURO-128 DROPS    
SODIUM CHLORIDE SODIUM CHLORIDE OINT. (G)    
SODIUM CHLORIDE MURO-128 OINT. (G)    
TETRACAINE HCL TETRACAINE HCL DROPS    
TETRACAINE HCL/PF TETRACAINE HCL DROPS    
TETRAHYDROZOLINE HCL EYE DROPS DROPS    
TETRAHYDROZOLINE HCL OPTI-CLEAR DROPS    
TETRAHYDROZOLINE HCL STERILE EYE DROPS DROPS    
TETRAHYDRZ/DEXT 70/PEG 400/PVP ADVANCED FORMULA EYE DROPS DROPS    
TETRAHYDRZ/DEXT 70/PEG 400/PVP EYE DROPS DROPS    
TETRAHYDRZ/DEXT 70/PEG 400/PVP EYE DROPS ADVANCED RELIEF DROPS    
TRIFLURIDINE TRIFLURIDINE DROPS    
TRIFLURIDINE VIROPTIC DROPS    
TROPICAMIDE TROPICAMIDE DROPS    
TROPICAMIDE MYDRIACYL DROPS    
VERTEPORFIN VISUDYNE VIAL