Antibiotic-Steroids, 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
00574414435 NEO-POLYCIN HC neomycin/bacit/p-myx/hydrocort OINT. (G) 3.5 mg-400 unit-10,000 unit/gram-1 % N Y  
24208078555 NEOMYCIN-BACITRACIN-POLY-HC neomycin/bacit/p-myx/hydrocort OINT. (G) 3.5 mg-400 unit-10,000 unit/gram-1 % N Y  
24208095560 NEOMYCIN W/DEXAMETHASONE neomycin/dexamethasone sod ph DROPS 0.35 %-0.1 % N Y  
00078079205 MAXITROL neomycin/polymyxin B/dexametha DROPS SUSP 3.5 mg/mL-10,000 unit/mL-0.1 % Y Y  
00998063006 MAXITROL neomycin/polymyxin B/dexametha DROPS SUSP 3.5 mg/mL-10,000 unit/mL-0.1 % Y Y  
82667010005 MAXITROL neomycin/polymyxin B/dexametha DROPS SUSP 3.5 mg/mL-10,000 unit/mL-0.1 % Y Y  
24208083060 NEOMYCIN-POLYMYXIN-DEXAMETH neomycin/polymyxin B/dexametha DROPS SUSP 3.5 mg/mL-10,000 unit/mL-0.1 % Y Y  
61314063006 NEOMYCIN-POLYMYXIN-DEXAMETH neomycin/polymyxin B/dexametha DROPS SUSP 3.5 mg/mL-10,000 unit/mL-0.1 % Y Y  
69918051505 NEOMYCIN-POLYMYXIN-DEXAMETH neomycin/polymyxin B/dexametha DROPS SUSP 3.5 mg/mL-10,000 unit/mL-0.1 % Y Y  
00078077101 MAXITROL neomycin/polymyxin B/dexametha OINT. (G) 3.5 mg/gram-10,000 unit/gram-0.1 % Y Y  
66758007038 MAXITROL neomycin/polymyxin B/dexametha OINT. (G) 3.5 mg/gram-10,000 unit/gram-0.1 % Y Y  
00574416035 NEOMYCIN-POLYMYXIN-DEXAMETH neomycin/polymyxin B/dexametha OINT. (G) 3.5 mg/gram-10,000 unit/gram-0.1 % Y Y  
24208079535 NEOMYCIN-POLYMYXIN-DEXAMETH neomycin/polymyxin B/dexametha OINT. (G) 3.5 mg/gram-10,000 unit/gram-0.1 % Y Y  
61314063136 NEOMYCIN-POLYMYXIN-DEXAMETH neomycin/polymyxin B/dexametha OINT. (G) 3.5 mg/gram-10,000 unit/gram-0.1 % Y Y  
61314064175 NEOMYCIN-POLYMYXIN-HC neomycin/polymyxin B/hydrocort DROPS SUSP 3.5 mg-10,000 unit-10 mg/mL N Y  
24208063562 NEOMYCIN-POLYMYXIN-HC neomycin/polymyxin B/hydrocort DROPS SUSP 3.5 mg/mL-10,000 unit/mL-1 % Y Y  
61314064511 NEOMYCIN-POLYMYXIN-HC neomycin/polymyxin B/hydrocort DROPS SUSP 3.5 mg/mL-10,000 unit/mL-1 % Y Y  
64980044801 NEOMYCIN-POLYMYXIN-HC neomycin/polymyxin B/hydrocort DROPS SUSP 3.5 mg/mL-10,000 unit/mL-1 % Y Y  
24208031705 SULFACETAMIDE-PREDNISOLONE sulfacetamide/prednisolone sp DROPS 10 %-0.23 % (0.25 %) N Y  
71776003505 TOBRADEX ST tobramycin/dexamethasone DROPS SUSP 0.3 %-0.05 % Y Y  
82667001105 TOBRADEX ST tobramycin/dexamethasone DROPS SUSP 0.3 %-0.05 % Y Y  
00574403105 TOBRAMYCIN-DEXAMETHASONE tobramycin/dexamethasone DROPS SUSP 0.3 %-0.1 % Y Y  
00574403110 TOBRAMYCIN-DEXAMETHASONE tobramycin/dexamethasone DROPS SUSP 0.3 %-0.1 % Y Y  
00574403125 TOBRAMYCIN-DEXAMETHASONE tobramycin/dexamethasone DROPS SUSP 0.3 %-0.1 % Y Y  
24208029505 TOBRAMYCIN-DEXAMETHASONE tobramycin/dexamethasone DROPS SUSP 0.3 %-0.1 % Y Y  
24208029510 TOBRAMYCIN-DEXAMETHASONE tobramycin/dexamethasone DROPS SUSP 0.3 %-0.1 % Y Y  
24208029525 TOBRAMYCIN-DEXAMETHASONE tobramycin/dexamethasone DROPS SUSP 0.3 %-0.1 % Y Y  
61314064705 TOBRAMYCIN-DEXAMETHASONE tobramycin/dexamethasone DROPS SUSP 0.3 %-0.1 % Y Y  
61314064710 TOBRAMYCIN-DEXAMETHASONE tobramycin/dexamethasone DROPS SUSP 0.3 %-0.1 % Y Y  
61314064725 TOBRAMYCIN-DEXAMETHASONE tobramycin/dexamethasone DROPS SUSP 0.3 %-0.1 % Y Y  
00078087601 TOBRADEX tobramycin/dexamethasone OINT. (G) 0.3 %-0.1 % Y Y  
24208035805 ZYLET tobramycin/lotepred etab DROPS SUSP 0.3 %-0.5 % N Y  
24208035810 ZYLET tobramycin/lotepred etab DROPS SUSP 0.3 %-0.5 % N Y  
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