Misc Opthalmic Preparations

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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 Carveout
‐ Bill FFS		 Current Drug Use Criteria
00065859502 TRYPTYR acoltremon DROPERETTE 0.003 % Y N  
00065081701 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
00065081702 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
60219174802 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
60219174903 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
60219175008 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
60505622600 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
60505622601 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
60505622602 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
70069058101 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
70069058201 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
70069058301 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
70069071601 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
70756065125 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
70756065225 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
70756065335 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
72603026401 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
72603026402 ATROPINE SULFATE atropine sulfate DROPS 1 % Y N  
00065030315 ISOPTO ATROPINE atropine sulfate DROPS 1 % Y N  
24208082555 ATROPINE SULFATE atropine sulfate OINT. (G) 1 % Y N  
50268011835 ATROPINE SULFATE atropine sulfate OINT. (G) 1 % Y N  
82260000101 ATROPINE SULFATE atropine sulfate/PF DROPERETTE 1 % Y N  
00023000551 AMO ENDOSOL EXTRA balanced salt irrig soln no.1 IRRIG SOLN Y N  
00065080050 BSS PLUS balanced salt irrig soln no.1 IRRIG SOLN Y N  
00065080094 BSS PLUS balanced salt irrig soln no.1 IRRIG SOLN Y N  
00023085002 AMO ENDOSOL balanced salt irrig soln no.2 IRRIG SOLN Y N  
00023085050 AMO ENDOSOL balanced salt irrig soln no.2 IRRIG SOLN Y N  
00065079515 BSS balanced salt irrig soln no.2 IRRIG SOLN Y N  
00065079550 BSS balanced salt irrig soln no.2 IRRIG SOLN Y N  
00065179504 BSS balanced salt irrig soln no.2 IRRIG SOLN Y N  
00065053001 EYE-STREAM balanced salt soln non-surg 3 IRRIG SOLN Y N  
82260073405 FLUORESCEIN-BENOXINATE benoxinate HCl/fluorescein sod DROPS 0.4 %-0.3 % Y N  
00023695430 REFRESH DIGITAL PF carboxymethyl/gly/poly80/PF DROPERETTE 0.5 %-1 %-0.5 % Y N  
00023449130 REFRESH OPTIVE ADVANCED carboxymethyl/gly/poly80/PF DROPERETTE 0.5 %-1 %-0.5 % Y N  
00023577330 REFRESH OPTIVE MEGA-3 carboxymethyl/gly/poly80/PF DROPERETTE 0.5 %-1 %-0.5 % Y N  
00023715160 REFRESH OPTIVE MEGA-3 carboxymethyl/gly/poly80/PF DROPERETTE 0.5 %-1 %-0.5 % Y N  
00023695210 REFRESH DIGITAL carboxymethyl/glycerin/poly80 DROPS 0.5 %-1 %-0.5 % Y N  
00023430710 REFRESH OPTIVE ADVANCED carboxymethyl/glycerin/poly80 DROPS 0.5 %-1 %-0.5 % Y N  
00023430720 REFRESH OPTIVE ADVANCED carboxymethyl/glycerin/poly80 DROPS 0.5 %-1 %-0.5 % Y N  
00023341630 REFRESH OPTIVE SENSITIVE carboxymethylcell/glycerin/PF DROPERETTE 0.5 %-0.9 % Y N  
00023341660 REFRESH OPTIVE SENSITIVE carboxymethylcell/glycerin/PF DROPERETTE 0.5 %-0.9 % Y N  
00023451530 REFRESH RELIEVA PF carboxymethylcell/glycerin/PF DROPERETTE 0.5 %-1 % Y N  
00023663401 REFRESH RELIEVA PF carboxymethylcell/glycerin/PF DROPS 0.5 %-0.9 % Y N  
00023663410 REFRESH RELIEVA PF carboxymethylcell/glycerin/PF DROPS 0.5 %-0.9 % Y N  
00023663420 REFRESH RELIEVA PF carboxymethylcell/glycerin/PF DROPS 0.5 %-0.9 % Y N  
00023378210 REFRESH RELIEVA PF XTRA carboxymethylcell/glycerin/PF DROPS 0.5 %-0.9 % Y N  
00023378220 REFRESH RELIEVA PF XTRA carboxymethylcell/glycerin/PF DROPS 0.5 %-0.9 % Y N  
00023311010 REFRESH TEARS PF carboxymethylcell/glycerin/PF DROPS 0.5 %-0.9 % Y N  
00023324015 REFRESH OPTIVE carboxymethylcellulos/glycerin DROPS 0.5 %-0.9 % Y N  
00023663004 REFRESH RELIEVA carboxymethylcellulos/glycerin DROPS 0.5 %-0.9 % Y N  
00023663010 REFRESH RELIEVA carboxymethylcellulos/glycerin DROPS 0.5 %-0.9 % Y N  
00023545910 REFRESH OPTIVE carboxymethylcellulos/glycerin DROPS GEL 1 %-0.9 % Y N  
50268006530 CARBOXYMETHYLCELLULOSE SODIUM carboxymethylcellulose sodium DROPER GEL 1 % Y N  
00023455430 REFRESH CELLUVISC carboxymethylcellulose sodium DROPER GEL 1 % Y N  
50268006730 CARBOXYMETHYLCELLULOSE SODIUM carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
50268006750 CARBOXYMETHYLCELLULOSE SODIUM carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
50268006770 CARBOXYMETHYLCELLULOSE SODIUM carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
00536138792 LUBRICANT EYE DROP carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
00536138793 LUBRICANT EYE DROP carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
46122075656 LUBRICANT EYE DROP carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
70677119001 LUBRICANT EYE DROP carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
70000001201 LUBRICANT EYE DROPS carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
70000001202 LUBRICANT EYE DROPS carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
00023040330 REFRESH PLUS carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
00023040350 REFRESH PLUS carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
00023040370 REFRESH PLUS carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
00023548730 REFRESH PLUS carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
00023548750 REFRESH PLUS carboxymethylcellulose sodium DROPERETTE 0.5 % Y N  
00023182212 REFRESH CONTACTS carboxymethylcellulose sodium DROPS Y N  
00536138635 CARBOXYMETHYLCELLULOSE SODIUM carboxymethylcellulose sodium DROPS 0.5 % Y N  
00536138694 CARBOXYMETHYLCELLULOSE SODIUM carboxymethylcellulose sodium DROPS 0.5 % Y N  
50268006802 CARBOXYMETHYLCELLULOSE SODIUM carboxymethylcellulose sodium DROPS 0.5 % Y N  
50268006815 CARBOXYMETHYLCELLULOSE SODIUM carboxymethylcellulose sodium DROPS 0.5 % Y N  
42494044805 LUBRICANT EYE DROP carboxymethylcellulose sodium DROPS 0.5 % Y N  
70000070501 LUBRICANT EYE DROP carboxymethylcellulose sodium DROPS 0.5 % Y N  
70000070502 LUBRICANT EYE DROP carboxymethylcellulose sodium DROPS 0.5 % Y N  
00023079801 REFRESH TEARS carboxymethylcellulose sodium DROPS 0.5 % Y N  
00023079815 REFRESH TEARS carboxymethylcellulose sodium DROPS 0.5 % Y N  
50268006615 CARBOXYMETHYLCELLULOSE SODIUM carboxymethylcellulose sodium DRP LQ GEL 1 % Y N  
00023920515 REFRESH LIQUIGEL carboxymethylcellulose sodium DRP LQ GEL 1 % Y N  
71981002007 OXERVATE cenegermin-bkbj DROPS 0.002 % N Y N Pharmacy PA
82667030001 IHEEZO chloroprocaine HCl/PF DROPER GEL 3 % Y N  
00065039515 CYCLOGYL cyclopentolate HCl DROPS 0.5 % Y N  
00065039602 CYCLOGYL cyclopentolate HCl DROPS 1 % Y N  
00065039605 CYCLOGYL cyclopentolate HCl DROPS 1 % Y N  
24208073501 CYCLOPENTOLATE HCL cyclopentolate HCl DROPS 1 % Y N  
24208073506 CYCLOPENTOLATE HCL cyclopentolate HCl DROPS 1 % Y N  
61314039601 CYCLOPENTOLATE HCL cyclopentolate HCl DROPS 1 % Y N  
61314039603 CYCLOPENTOLATE HCL cyclopentolate HCl DROPS 1 % Y N  
00065039702 CYCLOGYL cyclopentolate HCl DROPS 2 % Y N  
00065039705 CYCLOGYL cyclopentolate HCl DROPS 2 % Y N  
00065039715 CYCLOGYL cyclopentolate HCl DROPS 2 % Y N  
00065035902 CYCLOMYDRIL cyclopentolate/phenylephrine DROPS 0.2 %-1 % Y N  
00065035905 CYCLOMYDRIL cyclopentolate/phenylephrine DROPS 0.2 %-1 % Y N  
55292041005 CYSTADROPS cysteamine HCl DROPS 0.37 % Y N  
54482002002 CYSTARAN cysteamine HCl DROPS 0.44 % Y N  
00023334807 OZURDEX dexamethasone IMPLANT 0.7 mg N Y N  
00065041918 BION TEARS dextran 70/hypromellose/PF DROPERETTE 0.1 %-0.3 % Y N  
00065930501 BION TEARS dextran 70/hypromellose/PF DROPERETTE 0.1 %-0.3 % Y N  
00065806301 GENTEAL TEARS dextran 70/hypromellose/PF DROPERETTE 0.1 %-0.3 % Y N  
00065041632 TEARS NATURALE FREE dextran 70/hypromellose/PF DROPERETTE 0.1 %-0.3 % Y N  
50268004315 ARTIFICIAL TEARS dextran/hypromellose/glycerin DROPS 0.1 %-0.3 %-0.2 % Y N  
00065042636 GENTEAL TEARS dextran/hypromellose/glycerin DROPS 0.1 %-0.3 %-0.2 % Y N  
00065042637 GENTEAL TEARS dextran/hypromellose/glycerin DROPS 0.1 %-0.3 %-0.2 % Y N  
00065042615 TEARS NATURALE FORTE dextran/hypromellose/glycerin DROPS 0.1 %-0.3 %-0.2 % Y N  
00065026507 EPINAL epinephryl borate DROPS 0.5 % Y N  
00065026407 EPINAL epinephryl borate DROPS 1 % Y N  
00065805202 SYSTANE eyelid cleanser combination 9 TOWELETTE Y N  
68611018001 YUTIQ fluocinolone acetonide IMPLANT 0.18 mg Y N  
71879013601 YUTIQ fluocinolone acetonide IMPLANT 0.18 mg Y N  
68611019002 ILUVIEN fluocinolone acetonide IMPLANT 0.19 mg N Y N  
24208041601 RETISERT fluocinolone acetonide IMPLANT 0.59 mg N Y N  
24208053535 ZIRGAN ganciclovir GEL (GRAM) 0.15 % Y N  
00009029703 GELFILM gelatin EACH 25 mm X 50 mm Y N  
69918062501 BIOLON hyaluronate sodium SYRINGE 10 mg/mL Y N  
50474063699 HEALON5 PRO hyaluronate sodium SYRINGE 23 mg/mL Y N  
24208080060 LACRISERT hydroxypropyl cellulose INSERT 5 mg Y N  
00065040872 TEARS LUBRICANT EYE DROP hypromellose DROPS 0.5 % Y N  
00065806401 GENTEAL TEARS SEVERE hypromellose GEL (GRAM) 0.3 % Y N  
00065047401 SYSTANE GEL hypromellose GEL (GRAM) 0.3 % Y N  
82584079201 AKTEN lidocaine HCl/PF GEL (ML) 3.5 % Y N  
82584079225 AKTEN lidocaine HCl/PF GEL (ML) 3.5 % Y N  
81942012501 XDEMVY lotilaner DROPS 0.25 % Y N  
00904648838 LUBRIFRESH PM mineral oil/petrolatum,white OINT. (G) 15 %-83 % Y N  
00904754012 LUBRIFRESH PM mineral oil/petrolatum,white OINT. (G) 15 %-83 % Y N  
00065051801 GENTEAL TEARS SEVERE mineral oil/petrolatum,white OINT. (G) 3 %-94 % Y N  
00065050935 SYSTANE mineral oil/petrolatum,white OINT. (G) 3 %-94 % Y N  
00023031204 REFRESH LACRI-LUBE mineral oil/petrolatum,white OINT. (G) 42.5 %-56.8 % Y N  
46122075737 NIGHTTIME RELIEF LUBRICANT EYE mineral oil/petrolatum,white OINT. (G) 42.5 %-57.3 % Y N  
00023024004 REFRESH P.M. mineral oil/petrolatum,white OINT. (G) 42.5 %-57.3 % Y N  
00023066704 REFRESH P.M. mineral oil/petrolatum,white OINT. (G) 42.5 %-57.3 % Y N  
00603717841 NAPHAZOLINE HCL naphazoline HCl DROPS 0.1 % Y N  
00065008515 NAPHCON-A naphazoline HCl/pheniramine DROPS 0.025 %-0.3 % Y N  
24208043015 OPCON-A naphazoline HCl/pheniramine DROPS 0.02675 %-0.315 % Y N  
46122060505 DRY EYE RELIEF peg 400/hypromellose/glycerin DROPS 1 %-0.2 %-0.2 % Y N  
70000050201 DRY EYE RELIEF peg 400/hypromellose/glycerin DROPS 1 %-0.2 %-0.2 % Y N  
83368007530 RYZUMVI phentolamine mesylate/PF DROPERETTE 0.75 % Y N  
42702010305 PHENYLEPHRINE HCL phenylephrine HCl DROPS 10 % Y N  
65145015001 PHENYLEPHRINE HCL phenylephrine HCl DROPS 10 % Y N  
69315032405 PHENYLEPHRINE HCL phenylephrine HCl DROPS 10 % Y N  
70512086605 PHENYLEPHRINE HCL phenylephrine HCl DROPS 10 % Y N  
70756061430 PHENYLEPHRINE HCL phenylephrine HCl DROPS 10 % Y N  
72603053001 PHENYLEPHRINE HCL phenylephrine HCl DROPS 10 % Y N  
75907013023 PHENYLEPHRINE HCL phenylephrine HCl DROPS 10 % Y N  
82260010305 PHENYLEPHRINE HCL phenylephrine HCl DROPS 10 % Y N  
00065034904 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
00065034905 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
42702010210 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
65145014801 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
65145014901 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
69315032308 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
69315032315 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
70512086502 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
70512086515 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
70756062925 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
70756064935 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
72603052001 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
72603052002 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
75907012907 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
82260010210 PHENYLEPHRINE HCL phenylephrine HCl DROPS 2.5 % Y N  
62225060000 OMIDRIA phenylephrine/ketorolac VIAL 1 %-0.3 % Y N  
62225060004 OMIDRIA phenylephrine/ketorolac VIAL 1 %-0.3 % Y N  
62225060099 OMIDRIA phenylephrine/ketorolac VIAL 1 %-0.3 % Y N  
82604060000 OMIDRIA phenylephrine/ketorolac VIAL 1 %-0.3 % Y N  
82604060004 OMIDRIA phenylephrine/ketorolac VIAL 1 %-0.3 % Y N  
82604060099 OMIDRIA phenylephrine/ketorolac VIAL 1 %-0.3 % Y N  
24208067630 PILOCARPINE HCL pilocarpine HCl DROPS 1 % Y Y N  
61314020315 PILOCARPINE HCL pilocarpine HCl DROPS 1 % Y Y N  
69238174508 PILOCARPINE HCL pilocarpine HCl DROPS 1 % Y Y N  
70069018101 PILOCARPINE HCL pilocarpine HCl DROPS 1 % Y Y N  
60219236602 PILOCARPINE HCL pilocarpine HCl DROPS 1.25 % N Y N  
60219264901 PILOCARPINE HCL pilocarpine HCl DROPS 1.25 % N Y N  
00074709802 VUITY pilocarpine HCl DROPS 1.25 % N Y N  
00074709804 VUITY pilocarpine HCl DROPS 1.25 % N Y N  
00074709806 VUITY pilocarpine HCl DROPS 1.25 % N Y N  
24208068130 PILOCARPINE HCL pilocarpine HCl DROPS 2 % Y Y N  
61314020415 PILOCARPINE HCL pilocarpine HCl DROPS 2 % Y Y N  
69238174608 PILOCARPINE HCL pilocarpine HCl DROPS 2 % Y Y N  
70069019101 PILOCARPINE HCL pilocarpine HCl DROPS 2 % Y Y N  
00603725341 PILOCARPINE HCL pilocarpine HCl DROPS 4 % Y Y N  
24208068630 PILOCARPINE HCL pilocarpine HCl DROPS 4 % Y Y N  
61314020615 PILOCARPINE HCL pilocarpine HCl DROPS 4 % Y Y N  
69238174708 PILOCARPINE HCL pilocarpine HCl DROPS 4 % Y Y N  
70069020101 PILOCARPINE HCL pilocarpine HCl DROPS 4 % Y Y N  
70677115701 DRY EYE RELIEF polyethylene glycol 400 DROPS 1 % Y N  
11980002515 LIQUIFILM TEARS polyvinyl alcohol DROPS 1.4 % Y N  
11980002530 LIQUIFILM TEARS polyvinyl alcohol DROPS 1.4 % Y N  
00536140894 POLYVINYL ALCOHOL polyvinyl alcohol DROPS 1.4 % Y N  
50268067815 POLYVINYL ALCOHOL polyvinyl alcohol DROPS 1.4 % Y N  
24385000605 ARTIFICIAL TEARS polyvinyl alcohol/povidone DROPS 0.5 %-0.6 % Y N  
70000001101 ARTIFICIAL TEARS polyvinyl alcohol/povidone DROPS 0.5 %-0.6 % Y N  
83324018914 ARTIFICIAL TEARS polyvinyl alcohol/povidone DROPS 0.5 %-0.6 % Y N  
00074557405 MURINE polyvinyl alcohol/povidone DROPS 1.4 %-0.6 % Y N  
00074557416 MURINE polyvinyl alcohol/povidone DROPS 1.4 %-0.6 % Y N  
00074557422 MURINE polyvinyl alcohol/povidone DROPS 1.4 %-0.6 % Y N  
71776000110 FRESHKOTE polyvinyl alcohol/povidone DROPS 2.7 %-2 % Y N  
00023050601 REFRESH CLASSIC polyvinyl alcohol/povidone/PF DROPERETTE 1.4 %-0.6 % Y N  
00023050650 REFRESH CLASSIC polyvinyl alcohol/povidone/PF DROPERETTE 1.4 %-0.6 % Y N  
67618015001 BETADINE povidone-iodine SOLUTION 10 % Y N  
67618015004 BETADINE povidone-iodine SOLUTION 10 % Y N  
67618015005 BETADINE povidone-iodine SOLUTION 10 % Y N  
67618015009 BETADINE povidone-iodine SOLUTION 10 % Y N  
67618015017 BETADINE povidone-iodine SOLUTION 10 % Y N  
67618015018 BETADINE povidone-iodine SOLUTION 10 % Y N  
00065041130 BETADINE povidone-iodine SOLUTION 5 % Y N  
67618015101 BETADINE povidone-iodine SOLUTION 7.5 % Y N  
67618015104 BETADINE povidone-iodine SOLUTION 7.5 % Y N  
00998001615 ALCAINE proparacaine HCl DROPS 0.5 % Y N  
24208073006 PROPARACAINE HCL proparacaine HCl DROPS 0.5 % Y N  
61314001601 PROPARACAINE HCL proparacaine HCl DROPS 0.5 % Y N  
70069060101 PROPARACAINE HCL proparacaine HCl DROPS 0.5 % Y N  
70756019335 PROPARACAINE HCL proparacaine HCl DROPS 0.5 % Y N  
70000001301 LUBRICANT EYE DROP propylene glycol DROPS 0.6 % Y N  
70000070601 LUBRICANT EYE DROP propylene glycol DROPS 0.6 % Y N  
71800003103 LUBRICANT EYE DROP propylene glycol DROPS 0.6 % Y N  
71800003106 LUBRICANT EYE DROP propylene glycol DROPS 0.6 % Y N  
83324002815 LUBRICANT EYE DROP propylene glycol DROPS 0.6 % Y N  
00065143302 SYSTANE BALANCE propylene glycol DROPS 0.6 % Y N  
00065143307 SYSTANE BALANCE propylene glycol DROPS 0.6 % Y N  
00065143311 SYSTANE BALANCE propylene glycol DROPS 0.6 % Y N  
00065048101 SYSTANE COMPLETE propylene glycol DROPS 0.6 % Y N  
00065048110 SYSTANE COMPLETE propylene glycol DROPS 0.6 % Y N  
00065048111 SYSTANE COMPLETE propylene glycol DROPS 0.6 % Y N  
00065048155 SYSTANE COMPLETE propylene glycol DROPS 0.6 % Y N  
83592004001 LUBRICANT EYE DROP propylene glycol DROPS 0.7 % Y N  
83592004002 LUBRICANT EYE DROP propylene glycol DROPS 0.7 % Y N  
46122060705 LUBRICANT EYE propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
50268012615 LUBRICANT EYE propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
70000045501 LUBRICANT EYE propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
70677116001 LUBRICANT EYE propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
70677116201 LUBRICANT EYE propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
83324002915 LUBRICANT EYE propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
00536121994 LUBRICATING EYE propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
00065042915 SYSTANE propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
00065042930 SYSTANE propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
00065042936 SYSTANE propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
00065143105 SYSTANE ULTRA propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
00065143118 SYSTANE ULTRA propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
00065143128 SYSTANE ULTRA propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
00065143141 SYSTANE ULTRA propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
70000045701 ULTRA LUBRICANT EYE propylene glycol/peg 400 DROPS 0.3 %-0.4 % Y N  
00065806701 GENTEAL TEARS SEVERE propylene glycol/peg 400 DROPS GEL 0.3 %-0.4 % Y N  
00065045407 SYSTANE GEL propylene glycol/peg 400 DROPS GEL 0.3 %-0.4 % Y N  
70000001701 LUBRICANT EYE propylene glycol/peg 400/PF DROPERETTE 0.3 %-0.4 % Y N  
00065043133 SYSTANE propylene glycol/peg 400/PF DROPERETTE 0.3 %-0.4 % Y N  
00065043156 SYSTANE propylene glycol/peg 400/PF DROPERETTE 0.3 %-0.4 % Y N  
00065143704 SYSTANE HYDRATION PF propylene glycol/peg 400/PF DROPERETTE 0.3 %-0.4 % Y N  
00065143205 SYSTANE ULTRA propylene glycol/peg 400/PF DROPERETTE 0.3 %-0.4 % Y N  
00065143206 SYSTANE ULTRA propylene glycol/peg 400/PF DROPERETTE 0.3 %-0.4 % Y N  
70000050101 ULTRA LUBRICANT EYE propylene glycol/peg 400/PF DROPERETTE 0.3 %-0.4 % Y N  
00065151000 SYSTANE HYDRATION PF propylene glycol/peg 400/PF DROPS 0.3 %-0.4 % Y N  
00065151006 SYSTANE HYDRATION PF propylene glycol/peg 400/PF DROPS 0.3 %-0.4 % Y N  
00065150782 SYSTANE ULTRA PF propylene glycol/peg 400/PF DROPS 0.3 %-0.4 % Y N  
00065150792 SYSTANE ULTRA PF propylene glycol/peg 400/PF DROPS 0.3 %-0.4 % Y N  
00065153004 SYSTANE COMPLETE PF propylene glycol/PF DROPERETTE 0.6 % Y N  
00065150928 SYSTANE COMPLETE PF propylene glycol/PF DROPS 0.6 % Y N  
00065150929 SYSTANE COMPLETE PF propylene glycol/PF DROPS 0.6 % Y N  
00065153001 SYSTANE COMPLETE PF propylene glycol/PF DROPS 0.6 % Y N  
00065329003 SYSTANE PRO PF propylene glycol/PF DROPS 0.6 % Y N  
00065329005 SYSTANE PRO PF propylene glycol/PF DROPS 0.6 % Y N  
82958050101 ENCELTO revakinagene taroretcel-lwey IMPLANT 200,000 to 440,000 cell Y N  
25357002503 PHOTREXA CROSS-LINKING riboflavin 5-phos/20 % dextran CMB DPVDP 0.146 %-0.146 % Y N  
25357002201 PHOTREXA VISCOUS riboflavin 5-phos/20 % dextran DROPS VISC 0.146 % Y N  
25357002301 PHOTREXA riboflavin 5-phosphate sod(B2) DROPS 0.146 % Y N  
00536122497 EYE WASH sod borate/boric ac/water/NaCl IRRIG SOLN Y N  
68599198101 EYE WASH sod borate/boric ac/water/NaCl IRRIG SOLN Y N  
70000001801 EYE WASH sod borate/boric ac/water/NaCl IRRIG SOLN Y N  
83324019204 EYE WASH sod borate/boric ac/water/NaCl IRRIG SOLN Y N  
24208027615 MURO-128 sodium chloride DROPS 2 % Y N  
24208027715 MURO-128 sodium chloride DROPS 5 % Y N  
00536125494 SODIUM CHLORIDE sodium chloride DROPS 5 % Y N  
24208038555 MURO-128 sodium chloride OINT. (G) 5 % Y N  
24208038556 MURO-128 sodium chloride OINT. (G) 5 % Y N  
00536125391 SODIUM CHLORIDE sodium chloride OINT. (G) 5 % Y N  
00023082503 LENS PLUS sodium chloride SPRAY 0.9 % Y N  
00023082508 LENS PLUS sodium chloride SPRAY 0.9 % Y N  
00023082512 LENS PLUS sodium chloride SPRAY 0.9 % Y N  
70069059601 TETRACAINE HCL tetracaine HCl DROPS 0.5 % Y N  
70069059701 TETRACAINE HCL tetracaine HCl DROPS 0.5 % Y N  
82260092005 TETRACAINE HCL tetracaine HCl DROPS 0.5 % Y N  
82260092015 TETRACAINE HCL tetracaine HCl DROPS 0.5 % Y N  
00065074114 TETRACAINE HCL tetracaine HCl/PF DROPS 0.5 % Y N  
00065054301 TRIESENCE triamcinolone acetonide/PF VIAL 40 mg/mL N Y N  
00078089778 TRIESENCE triamcinolone acetonide/PF VIAL 40 mg/mL N Y N  
82667080001 TRIESENCE triamcinolone acetonide/PF VIAL 40 mg/mL N Y N  
24208004001 XIPERE triamcinolone acetonide/PF VIAL 40 mg/mL (0.9 mL) Y N  
24208004002 XIPERE triamcinolone acetonide/PF VIAL 40 mg/mL (0.9 mL) Y N  
24208004040 XIPERE triamcinolone acetonide/PF VIAL 40 mg/mL (0.9 mL) Y N  
24208004041 XIPERE triamcinolone acetonide/PF VIAL 40 mg/mL (0.9 mL) Y N  
61314004475 TRIFLURIDINE trifluridine DROPS 1 % Y N  
24208059064 TROPICAMIDE tropicamide DROPS 0.5 % Y N  
61314035401 TROPICAMIDE tropicamide DROPS 0.5 % Y N  
00998035515 MYDRIACYL tropicamide DROPS 1 % Y N  
24208058559 TROPICAMIDE tropicamide DROPS 1 % Y N  
24208058564 TROPICAMIDE tropicamide DROPS 1 % Y N  
61314035501 TROPICAMIDE tropicamide DROPS 1 % Y N  
61314035502 TROPICAMIDE tropicamide DROPS 1 % Y N  
70069012101 TROPICAMIDE tropicamide DROPS 1 % Y N  
00065008315 ENUCLENE tyloxapol DROPS 0.25 % Y N  
71394006501 LUXTURNA voretigene neparvovec-rzyl VIAL 1.5 x 10exp11 vector genomes/0.3 mL (final conc.) Y N Pharmacy PA
71394041501 LUXTURNA voretigene neparvovec-rzyl VIAL 1.5 x 10exp11 vector genomes/0.3 mL (final conc.) Y N Pharmacy PA
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