Drugs for Dry Eye
PDL Reference Documents
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.
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 & Updates |
|---|---|---|---|---|---|
| cyclosporine | CEQUA | DROPERETTE | N | PA Document | |
| cyclosporine | VERKAZIA | DROPERETTE | N | PA Document | |
| cyclosporine | CYCLOSPORINE | DROPERETTE | N | PA Document | |
| cyclosporine | RESTASIS | DROPERETTE | N | PA Document | |
| cyclosporine | RESTASIS MULTIDOSE | DROPS | N | PA Document | |
| cyclosporine | VEVYE | DROPS | N | PA Document | |
| lifitegrast | XIIDRA | DROPERETTE | N | PA Document | Jan 26, 2017 |
| loteprednol etabonate | EYSUVIS | DROPS SUSP | N | PA Document | |
| perfluorohexyloctane/PF | MIEBO | DROPS | N | PA Document | |
| varenicline tartrate | TYRVAYA | SPRAY METR | N | Age Restriction |