Antibiotics, Ophthalmic

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
82584030703 AZASITE azithromycin DROPS 1 % N Y  
00363007564 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
00713028031 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
00927009430 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
11673007358 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
11917005749 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
11917018788 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
12810006003 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
16784011631 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
37097006003 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
41280020078 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
43072000638 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
49158012206 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
49158012208 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
49999014215 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
50090081500 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
51672200503 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
52959021706 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
52959133703 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
52959133706 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
52959137603 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
52959137605 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
54868326900 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
59390002617 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
59779053664 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
66267098830 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
66267098915 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
67777011620 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
67777011621 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
67777011630 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
67777011631 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
67777021901 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
71205005701 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
87701095027 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
94441020078 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y N  
00536125628 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y Y  
00574402235 BACITRACIN bacitracin OINT. (G) 500 unit/gram N Y  
45802006001 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y Y  
45802006003 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y Y  
45802006004 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y Y  
45802006005 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y Y  
45802006010 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y Y  
45802006023 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y Y  
45802006044 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y Y  
45861007303 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y Y  
68001047746 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y Y  
68001047747 BACITRACIN bacitracin OINT. (G) 500 unit/gram Y Y  
24208055555 BACITRACIN-POLYMYXIN bacitracin/polymyxin B sulfate OINT. (G) 500 unit-10,000 unit/gram Y Y  
00574402135 POLYCIN bacitracin/polymyxin B sulfate OINT. (G) 500 unit-10,000 unit/gram Y Y  
24208044605 BESIVANCE besifloxacin HCl DROPS SUSP 0.6 % N Y  
60793030701 CHLORAMPHENICOL chloramphenicol OINT. (G) 1 % N Y  
61314065605 CIPROFLOXACIN HCL ciprofloxacin HCl DROPS 0.3 % Y Y  
61314065610 CIPROFLOXACIN HCL ciprofloxacin HCl DROPS 0.3 % Y Y  
61314065625 CIPROFLOXACIN HCL ciprofloxacin HCl DROPS 0.3 % Y Y  
69315030802 CIPROFLOXACIN HCL ciprofloxacin HCl DROPS 0.3 % Y Y  
69315030805 CIPROFLOXACIN HCL ciprofloxacin HCl DROPS 0.3 % Y Y  
69315030810 CIPROFLOXACIN HCL ciprofloxacin HCl DROPS 0.3 % Y Y  
72888010221 CIPROFLOXACIN HCL ciprofloxacin HCl DROPS 0.3 % Y Y  
72888010222 CIPROFLOXACIN HCL ciprofloxacin HCl DROPS 0.3 % Y Y  
72888010223 CIPROFLOXACIN HCL ciprofloxacin HCl DROPS 0.3 % Y Y  
00078084101 CILOXAN ciprofloxacin HCl OINT. (G) 0.3 % Y Y  
66758007138 CILOXAN ciprofloxacin HCl OINT. (G) 0.3 % Y Y  
00574402411 ERYTHROMYCIN erythromycin base OINT. (G) 5 mg/gram (0.5 %) Y Y  
00574402435 ERYTHROMYCIN erythromycin base OINT. (G) 5 mg/gram (0.5 %) Y Y  
00574402439 ERYTHROMYCIN erythromycin base OINT. (G) 5 mg/gram (0.5 %) Y Y  
00574402450 ERYTHROMYCIN erythromycin base OINT. (G) 5 mg/gram (0.5 %) Y Y  
24208091019 ERYTHROMYCIN erythromycin base OINT. (G) 5 mg/gram (0.5 %) Y Y  
24208091055 ERYTHROMYCIN erythromycin base OINT. (G) 5 mg/gram (0.5 %) Y Y  
48102005711 ERYTHROMYCIN erythromycin base OINT. (G) 5 mg/gram (0.5 %) Y Y  
72485067031 ERYTHROMYCIN erythromycin base OINT. (G) 5 mg/gram (0.5 %) Y Y  
72485067035 ERYTHROMYCIN erythromycin base OINT. (G) 5 mg/gram (0.5 %) Y Y  
61314067225 GATIFLOXACIN gatifloxacin DROPS 0.5 % N Y  
11980011705 GENOPTIC gentamicin sulfate DROPS 0.3 % Y Y  
24208058060 GENTAMICIN SULFATE gentamicin sulfate DROPS 0.3 % Y Y  
61314063305 GENTAMICIN SULFATE gentamicin sulfate DROPS 0.3 % Y Y  
72888014222 LEVOFLOXACIN levofloxacin DROPS 0.5 % N Y  
00781713593 MOXIFLOXACIN moxifloxacin HCl DROPS 0.5 % Y Y  
00832141003 MOXIFLOXACIN moxifloxacin HCl DROPS 0.5 % Y Y  
16714064301 MOXIFLOXACIN moxifloxacin HCl DROPS 0.5 % Y Y  
60505058204 MOXIFLOXACIN moxifloxacin HCl DROPS 0.5 % Y Y  
62332050503 MOXIFLOXACIN moxifloxacin HCl DROPS 0.5 % Y Y  
65862084003 MOXIFLOXACIN moxifloxacin HCl DROPS 0.5 % Y Y  
68180042201 MOXIFLOXACIN moxifloxacin HCl DROPS 0.5 % Y Y  
70069008101 MOXIFLOXACIN moxifloxacin HCl DROPS 0.5 % Y Y  
70756063825 MOXIFLOXACIN moxifloxacin HCl DROPS 0.5 % Y Y  
72266015801 MOXIFLOXACIN moxifloxacin HCl DROPS 0.5 % Y Y  
00078093926 VIGAMOX moxifloxacin HCl DROPS 0.5 % Y Y  
82667070003 VIGAMOX moxifloxacin HCl DROPS 0.5 % Y Y  
71776000515 NATACYN natamycin DROPS SUSP 5 % Y Y  
82667001205 NATACYN natamycin DROPS SUSP 5 % Y Y  
00574425035 NEO-POLYCIN neomycin/bacitracin/polymyxinB OINT. (G) 3.5 mg-400 unit-10,000 unit/gram N Y  
16571075453 NEOMYCIN-BACITRACIN-POLYMYXIN neomycin/bacitracin/polymyxinB OINT. (G) 3.5 mg-400 unit-10,000 unit/gram N Y  
24208078055 NEOMYCIN-BACITRACIN-POLYMYXIN neomycin/bacitracin/polymyxinB OINT. (G) 3.5 mg-400 unit-10,000 unit/gram N Y  
60793026610 NEOMYCIN/POLYMYXIN/GRAMICIDIN neomycin/polymyxn B/gramicidin DROPS Y Y  
00603722539 NEOPTIC neomycin/polymyxn B/gramicidin DROPS Y Y  
24208079062 NEOMYCIN-POLYMYXIN-GRAMICIDIN neomycin/polymyxn B/gramicidin DROPS 1.75 mg-10,000 unit-0.025 mg/mL Y Y  
11980077905 OCUFLOX ofloxacin DROPS 0.3 % Y Y  
00904743405 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
00904743410 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
24208041005 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
24208041010 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
24208043405 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
24208043410 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
60505036301 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
60505036302 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
60505056000 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
60505056001 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
64980043201 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
64980043205 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
64980051501 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
64980051505 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
65145014101 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
65145014201 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
65145014301 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
65145014401 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
69238161503 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
69238161606 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
69315032005 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
69315032010 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
69315032705 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
69315032710 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
70069041101 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
70069068601 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
70069068701 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
70512079305 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
70512079310 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
70756060730 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
70756060915 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
70756061030 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
70756065030 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
72485061310 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
72485061311 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
72603018601 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
72603018602 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
72603019201 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
72603019202 OFLOXACIN ofloxacin DROPS 0.3 % Y Y  
00049080108 TERRAMYCIN WITH POLYMYXIN oxytetracycline/polymyxin B OINT. (G) 5 mg-10,000 unit/gram N Y  
24208031510 POLYMYXIN B SUL-TRIMETHOPRIM polymyxin B sulf/trimethoprim DROPS 10,000 unit-1 mg/mL Y Y  
61314062810 POLYMYXIN B SUL-TRIMETHOPRIM polymyxin B sulf/trimethoprim DROPS 10,000 unit-1 mg/mL Y Y  
70069031101 POLYMYXIN B SUL-TRIMETHOPRIM polymyxin B sulf/trimethoprim DROPS 10,000 unit-1 mg/mL Y Y  
00603728041 SULFACETAMIDE SODIUM sulfacetamide sodium DROPS 10 % Y Y  
24208067004 SULFACETAMIDE SODIUM sulfacetamide sodium DROPS 10 % Y Y  
00998052205 ISOPTO CETAMIDE sulfacetamide sodium DROPS 15 % Y Y  
00574419035 SULFACETAMIDE SODIUM sulfacetamide sodium OINT. (G) 10 % N Y  
24208029005 TOBRAMYCIN tobramycin DROPS 0.3 % Y Y  
61314064305 TOBRAMYCIN tobramycin DROPS 0.3 % Y Y  
62332051805 TOBRAMYCIN tobramycin DROPS 0.3 % Y Y  
70069013101 TOBRAMYCIN tobramycin DROPS 0.3 % Y Y  
00078081301 TOBREX tobramycin OINT. (G) 0.3 % Y Y  
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