Misc Opthalmic Preparations
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| cenegermin-bkbj | OXERVATE | DROPS | N | Pharmacy PA | N | Dec 03, 2020 |
| dexamethasone | OZURDEX | IMPLANT | N | N | ||
| fluocinolone acetonide | ILUVIEN | IMPLANT | N | N | ||
| pilocarpine HCl | PILOCARPINE HCL | DROPS | N | N | ||
| acoltremon | TRYPTYR | DROPERETTE | N | |||
| atropine sulfate | ISOPTO ATROPINE | DROPS | N | |||
| atropine sulfate | ATROPINE SULFATE | OINT. (G) | N | |||
| atropine sulfate/PF | ATROPINE SULFATE | DROPERETTE | N | |||
| balanced salt irrig soln no.1 | BSS PLUS | IRRIG SOLN | N | |||
| balanced salt irrig soln no.2 | BSS | IRRIG SOLN | N | |||
| benoxinate HCl/fluorescein sod | FLUORESCEIN-BENOXINATE | DROPS | N | |||
| carboxymethylcell/glycerin/PF | REFRESH RELIEVA PF | DROPERETTE | N | |||
| carboxymethylcell/glycerin/PF | REFRESH OPTIVE SENSITIVE | DROPERETTE | N | |||
| carboxymethylcell/glycerin/PF | REFRESH TEARS PF | DROPS | N | |||
| carboxymethylcellulos/glycerin | REFRESH OPTIVE | DROPS | N | |||
| carboxymethylcellulos/glycerin | REFRESH OPTIVE | DROPS GEL | N | |||
| carboxymethylcellulose sodium | CARBOXYMETHYLCELLULOSE SODIUM | DROPER GEL | N | |||
| carboxymethylcellulose sodium | REFRESH CELLUVISC | DROPER GEL | N | |||
| carboxymethylcellulose sodium | LUBRICANT EYE DROPS | DROPERETTE | N | |||
| carboxymethylcellulose sodium | LUBRICANT EYE DROP | DROPERETTE | N | |||
| carboxymethylcellulose sodium | REFRESH PLUS | DROPERETTE | N | |||
| carboxymethylcellulose sodium | CARBOXYMETHYLCELLULOSE SODIUM | DROPS | N | |||
| cyclopentolate HCl | CYCLOPENTOLATE HCL | DROPS | N | |||
| cyclopentolate HCl | CYCLOGYL | DROPS | N | |||
| cysteamine HCl | CYSTADROPS | DROPS | N | |||
| dextran 70/hypromellose/PF | BION TEARS | DROPERETTE | N | |||
| dextran 70/hypromellose/PF | GENTEAL TEARS | DROPERETTE | N | |||
| dextran/hypromellose/glycerin | GENTEAL TEARS | DROPS | N | |||
| dextran/hypromellose/glycerin | ARTIFICIAL TEARS | DROPS | N | |||
| epinephryl borate | EPINAL | DROPS | N | |||
| hyaluronate sodium | HEALON5 PRO | SYRINGE | N | |||
| hypromellose | TEARS LUBRICANT EYE DROP | DROPS | N | |||
| mineral oil/petrolatum,white | LUBRIFRESH PM | OINT. (G) | N | |||
| mineral oil/petrolatum,white | REFRESH LACRI-LUBE | OINT. (G) | N | |||
| mineral oil/petrolatum,white | SYSTANE | OINT. (G) | N | |||
| naphazoline HCl | NAPHAZOLINE HCL | DROPS | N | |||
| naphazoline HCl/pheniramine | OPCON-A | DROPS | N | |||
| naphazoline HCl/pheniramine | NAPHCON-A | DROPS | N | |||
| peg 400/hypromellose/glycerin | DRY EYE RELIEF | DROPS | N | |||
| phentolamine mesylate/PF | RYZUMVI | DROPERETTE | N | |||
| phenylephrine HCl | PHENYLEPHRINE HCL | DROPS | N | |||
| polyvinyl alcohol | LIQUIFILM TEARS | DROPS | N | |||
| polyvinyl alcohol/povidone | ARTIFICIAL TEARS | DROPS | N | |||
| polyvinyl alcohol/povidone | MURINE | DROPS | N | |||
| proparacaine HCl | ALCAINE | DROPS | N | |||
| propylene glycol | SYSTANE COMPLETE | DROPS | N | |||
| propylene glycol/peg 400 | LUBRICANT EYE | DROPS | N | |||
| propylene glycol/peg 400 | ULTRA LUBRICANT EYE | DROPS | N | |||
| propylene glycol/peg 400 | SYSTANE GEL | DROPS GEL | N | |||
| propylene glycol/peg 400/PF | LUBRICANT EYE | DROPERETTE | N | |||
| propylene glycol/peg 400/PF | SYSTANE | DROPERETTE | N | |||
| propylene glycol/peg 400/PF | SYSTANE HYDRATION PF | DROPS | N | |||
| propylene glycol/peg 400/PF | SYSTANE ULTRA PF | DROPS | N | |||
| propylene glycol/PF | SYSTANE COMPLETE PF | DROPERETTE | N | |||
| propylene glycol/PF | SYSTANE COMPLETE PF | DROPS | N | |||
| revakinagene taroretcel-lwey | ENCELTO | IMPLANT | N | |||
| riboflavin 5-phos/20 % dextran | PHOTREXA CROSS-LINKING | CMB DPVDP | N | |||
| sodium chloride | MURO-128 | OINT. (G) | N | |||
| sodium chloride | SODIUM CHLORIDE | OINT. (G) | N | |||
| tetracaine HCl | TETRACAINE HCL | DROPS | N | |||
| tetracaine HCl/PF | TETRACAINE HCL | DROPS | N | |||
| triamcinolone acetonide/PF | XIPERE | VIAL | N | |||
| tropicamide | MYDRIACYL | DROPS | N | |||
| tyloxapol | ENUCLENE | DROPS | N |