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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 00378876058 | CYCLOSPORINE | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 00378876091 | CYCLOSPORINE | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 00378876098 | CYCLOSPORINE | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 10702080803 | CYCLOSPORINE | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 10702080806 | CYCLOSPORINE | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 60505620201 | CYCLOSPORINE | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 60505620202 | CYCLOSPORINE | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 68180021430 | CYCLOSPORINE | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 68180021460 | CYCLOSPORINE | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 73043000501 | CYCLOSPORINE | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 73043000502 | CYCLOSPORINE | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 00023916330 | RESTASIS | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 00023916360 | RESTASIS | cyclosporine | DROPERETTE | 0.05 % | N | Y | PA Document |
| 47335050696 | CEQUA | cyclosporine | DROPERETTE | 0.09 % | N | Y | PA Document |
| 47335050797 | CEQUA | cyclosporine | DROPERETTE | 0.09 % | N | Y | PA Document |
| 65086000112 | VERKAZIA | cyclosporine | DROPERETTE | 0.1 % | N | Y | PA Document |
| 00023530101 | RESTASIS MULTIDOSE | cyclosporine | DROPS | 0.05 % | N | Y | PA Document |
| 00023530105 | RESTASIS MULTIDOSE | cyclosporine | DROPS | 0.05 % | N | Y | PA Document |
| 82667090002 | VEVYE | cyclosporine | DROPS | 0.1 % | N | Y | PA Document |
| 00078091105 | XIIDRA | lifitegrast | DROPERETTE | 5 % | N | Y | PA Document |
| 00078091112 | XIIDRA | lifitegrast | DROPERETTE | 5 % | N | Y | PA Document |
| 24208091105 | XIIDRA | lifitegrast | DROPERETTE | 5 % | N | Y | PA Document |
| 24208091112 | XIIDRA | lifitegrast | DROPERETTE | 5 % | N | Y | PA Document |
| 24208091194 | XIIDRA | lifitegrast | DROPERETTE | 5 % | N | Y | PA Document |
| 24208091195 | XIIDRA | lifitegrast | DROPERETTE | 5 % | N | Y | PA Document |
| 71571033383 | EYSUVIS | loteprednol etabonate | DROPS SUSP | 0.25 % | N | Y | PA Document |
| 24208037705 | MIEBO | perfluorohexyloctane/PF | DROPS | 100 % | N | Y | PA Document |
| 73521003001 | TYRVAYA | varenicline tartrate | SPRAY METR | 0.03 mg/spray | N | Y | Age Restriction |
| 73521003002 | TYRVAYA | varenicline tartrate | SPRAY METR | 0.03 mg/spray | N | Y | Age Restriction |
| 73521003090 | TYRVAYA | varenicline tartrate | SPRAY METR | 0.03 mg/spray | N | Y | Age Restriction |