Anti-Inflammatory Drugs, Ophthalmic
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.
| Generic Name | Brand Name | Form | PDL Status |
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 | ||
| fluorometholone | FLUOROMETHOLONE | DROPS SUSP | Y | ||
| fluorometholone | FML | DROPS SUSP | Y | ||
| flurbiprofen sodium | FLURBIPROFEN SODIUM | DROPS | Y | ||
| ketorolac tromethamine | KETOROLAC TROMETHAMINE | DROPS | Y | ||
| ketorolac tromethamine | ACULAR | DROPS | Y | ||
| ketorolac tromethamine | ACULAR LS | DROPS | Y | ||
| loteprednol etabonate | LOTEMAX | DROPS SUSP | Y | ||
| loteprednol etabonate | LOTEPREDNOL ETABONATE | DROPS SUSP | Y | ||
| prednisolone acetate | PRED FORTE | DROPS SUSP | Y | ||
| prednisolone acetate | PREDNISOLONE ACETATE | DROPS SUSP | Y | ||
| bromfenac sodium | BROMSITE | DROPS | N | ||
| bromfenac sodium | BROMFENAC SODIUM | DROPS | N | ||
| bromfenac sodium | PROLENSA | DROPS | N | ||
| difluprednate | DUREZOL | DROPS | N | ||
| difluprednate | DIFLUPREDNATE | DROPS | N | ||
| fluorometholone | FML FORTE | DROPS SUSP | N | ||
| fluorometholone acetate | FLAREX | DROPS SUSP | N | ||
| ketorolac tromethamine/PF | ACUVAIL | DROPERETTE | N | ||
| loteprednol etabonate | LOTEMAX SM | DROPS GEL | N | ||
| loteprednol etabonate | LOTEMAX | DROPS GEL | N | ||
| loteprednol etabonate | LOTEPREDNOL ETABONATE | DROPS GEL | N | ||
| loteprednol etabonate | EYSUVIS | DROPS SUSP | N | ||
| loteprednol etabonate | INVELTYS | DROPS SUSP | N | ||
| loteprednol etabonate | ALREX | 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 | ||
| dexamethasone | DEXTENZA | INSERT |