Antibiotic-Steroids, 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
gentamicin sulf/prednisolone PRED-G DROPS SUSP Y    
gentamicin sulf/prednisolone PRED-G OINT. (G) Y    
neomycin/polymyxin B/dexametha NEOMYCIN-POLYMYXIN-DEXAMETH DROPS SUSP Y    
neomycin/polymyxin B/dexametha MAXITROL DROPS SUSP Y    
neomycin/polymyxin B/dexametha NEOMYCIN-POLYMYXIN-DEXAMETH OINT. (G) Y    
neomycin/polymyxin B/dexametha MAXITROL OINT. (G) Y    
neomycin/polymyxin B/hydrocort NEOMYCIN-POLYMYXIN-HC DROPS SUSP Y 3.5 mg-10,000 unit-10 mg/mL Require PA  
sulfacetamide/prednisolone BLEPHAMIDE DROPS SUSP Y    
sulfacetamide/prednisolone BLEPHAMIDE S.O.P. OINT. (G) Y    
tobramycin/dexamethasone TOBRAMYCIN-DEXAMETHASONE DROPS SUSP Y    
tobramycin/dexamethasone TOBRADEX ST DROPS SUSP Y    
tobramycin/dexamethasone TOBRADEX DROPS SUSP Y    
tobramycin/dexamethasone TOBRADEX OINT. (G) Y    
neomycin/bacit/p-myx/hydrocort NEO-POLYCIN HC OINT. (G) N    
neomycin/bacit/p-myx/hydrocort NEOMYCIN-BACITRACIN-POLY-HC OINT. (G) N    
neomycin/bacit/p-myx/hydrocort AK-SPORE H.C. OINT. (G) N    
neomycin/dexamethasone sod ph NEOMYCIN W/DEXAMETHASONE DROPS N    
sulfacetamide/prednisolone sp SULFACETAMIDE-PREDNISOLONE DROPS N    
tobramycin/lotepred etab ZYLET DROPS SUSP N