Glaucoma Drugs

← Back to Class List

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
Status
Current Drug Use Criteria New Drug Evaluation
betaxolol HCl BETAXOLOL HCL DROPS Y    
brimonidine tartrate ALPHAGAN P DROPS Y 0.1 % Require PA  
brimonidine tartrate BRIMONIDINE TARTRATE DROPS Y    
brinzolamide AZOPT DROPS SUSP Y    
carteolol HCl CARTEOLOL HCL DROPS Y    
dorzolamide HCl/timolol maleat COSOPT DROPS Y    
dorzolamide HCl/timolol maleat DORZOLAMIDE-TIMOLOL DROPS Y    
dorzolamide/timolol/PF DORZOLAMIDE-TIMOLOL DROPERETTE Y    
dorzolamide/timolol/PF COSOPT PF DROPERETTE Y    
latanoprost XALATAN DROPS Y    
latanoprost LATANOPROST DROPS Y    
pilocarpine HCl ISOPTO CARPINE DROPS Y    
pilocarpine HCl PILOCARPINE HCL DROPS Y    
timolol maleate TIMOLOL MALEATE DROPS Y    
timolol maleate TIMOPTIC DROPS Y    
travoprost TRAVATAN Z DROPS Y    
acetylcholine chloride MIOCHOL-E KIT N    
apraclonidine HCl IOPIDINE DROPERETTE N    
apraclonidine HCl APRACLONIDINE HCL DROPS N    
apraclonidine HCl IOPIDINE DROPS N    
betaxolol HCl BETOPTIC S DROPS SUSP N    
bimatoprost BIMATOPROST DROPS N    
bimatoprost LUMIGAN DROPS N    
brimonidine tartrate/timolol COMBIGAN DROPS N    
brinzolamide/brimonidine tart SIMBRINZA DROPS SUSP N    
carbachol MIOSTAT VIAL N    
dorzolamide HCl DORZOLAMIDE HCL DROPS N    
dorzolamide HCl TRUSOPT DROPS N    
echothiophate iodide PHOSPHOLINE IODIDE DROPS N    
latanoprostene bunod VYZULTA DROPS N    
levobunolol HCl LEVOBUNOLOL HCL DROPS N    
levobunolol HCl BETAGAN DROPS N    
netarsudil mesylate RHOPRESSA DROPS N    
tafluprost/PF ZIOPTAN DROPERETTE N    
timolol maleate ISTALOL DROP DAILY N    
timolol maleate TIMOLOL MALEATE DROP DAILY N    
timolol maleate TIMOLOL MALEATE SOL-GEL N    
timolol maleate TIMOPTIC-XE SOL-GEL N    
timolol maleate/PF TIMOPTIC OCUDOSE DROPERETTE N