Anti-Inflammatory Drugs, Ophthalmic

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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 but eligible patients will encounter a co-pay at the pharmacy.
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
Current Drug Use Criteria New Drug Evaluation
dexamethasone MAXIDEX DROPS SUSP Y    
dexamethasone sodium phosphate DEXAMETHASONE SODIUM PHOSPHATE DROPS Y    
diclofenac sodium DICLOFENAC SODIUM DROPS Y 1.5 % Require PA  
fluorometholone FML DROPS SUSP Y    
fluorometholone FML S.O.P. OINT. (G) Y    
flurbiprofen sodium FLURBIPROFEN SODIUM DROPS Y    
ketorolac tromethamine KETOROLAC TROMETHAMINE DROPS Y    
ketorolac tromethamine ACULAR LS DROPS Y    
ketorolac tromethamine ACULAR DROPS Y    
loteprednol etabonate LOTEMAX DROPS SUSP Y    
prednisolone acetate PRED FORTE DROPS SUSP Y    
prednisolone acetate PREDNISOLONE ACETATE DROPS SUSP Y    
prednisolone acetate OMNIPRED DROPS SUSP Y    
bromfenac sodium PROLENSA DROPS N    
bromfenac sodium BROMSITE DROPS N    
bromfenac sodium BROMFENAC SODIUM DROPS N    
difluprednate DUREZOL DROPS N    
fluorometholone FML FORTE DROPS SUSP N    
fluorometholone acetate FLAREX DROPS SUSP N    
ketorolac tromethamine/PF ACUVAIL DROPERETTE N    
loteprednol etabonate LOTEMAX DROPS GEL N    
loteprednol etabonate ALREX DROPS SUSP N    
loteprednol etabonate INVELTYS DROPS SUSP N    
loteprednol etabonate LOTEMAX OINT. (G) N    
nepafenac ILEVRO DROPS SUSP N    
nepafenac NEVANAC DROPS SUSP N    
prednisolone acetate PRED MILD DROPS SUSP N    
prednisolone sodium phosphate PREDNISOLONE SODIUM PHOSPHATE DROPS N    
loteprednol etabonate LOTEMAX SM DROPS GEL