Antibiotics, 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.
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
bacitracin/polymyxin B sulfate POLYCIN OINT. (G) Y    
bacitracin/polymyxin B sulfate BACITRACIN-POLYMYXIN OINT. (G) Y    
bacitracin/polymyxin B sulfate AK-POLY-BAC OINT. (G) Y    
ciprofloxacin HCl CILOXAN DROPS Y    
ciprofloxacin HCl CILOXAN OINT. (G) Y    
erythromycin base ERYTHROMYCIN OINT. (G) Y    
gentamicin sulfate GENOPTIC DROPS Y    
gentamicin sulfate GENTAMICIN SULFATE DROPS Y    
gentamicin sulfate GENTAK OINT. (G) Y    
moxifloxacin HCl MOXIFLOXACIN DROPS Y    
moxifloxacin HCl VIGAMOX DROPS Y    
natamycin NATACYN DROPS SUSP Y    
neomycin/polymyxn B/gramicidin NEOPTIC DROPS Y    
neomycin/polymyxn B/gramicidin NEOMYCIN-POLYMYXIN-GRAMICIDIN DROPS Y    
neomycin/polymyxn B/gramicidin NEOMYCIN/POLYMYXIN/GRAMICIDIN DROPS Y    
ofloxacin OFLOXACIN DROPS Y    
ofloxacin OCUFLOX DROPS Y    
polymyxin B sulf/trimethoprim POLYMYXIN B SUL-TRIMETHOPRIM DROPS Y    
polymyxin B sulf/trimethoprim POLYTRIM DROPS Y    
sulfacetamide sodium SULFACETAMIDE SODIUM DROPS Y    
sulfacetamide sodium ISOPTO CETAMIDE DROPS Y    
tobramycin TOBRAMYCIN DROPS Y    
tobramycin TOBREX DROPS Y    
tobramycin TOBREX OINT. (G) Y    
azithromycin AZASITE DROPS N    
bacitracin AK-TRACIN OINT. (G) N    
bacitracin BACIGUENT OINT. (G) N    
bacitracin BACITRACIN OINT. (G) N    
besifloxacin HCl BESIVANCE DROPS SUSP N    
chloramphenicol CHLORAMPHENICOL OINT. (G) N    
gatifloxacin ZYMAXID DROPS N    
gatifloxacin GATIFLOXACIN DROPS N    
levofloxacin LEVOFLOXACIN DROPS N    
neomycin/bacitracin/polymyxinB NEOMYCIN-BACITRACIN-POLYMYXIN OINT. (G) N    
neomycin/bacitracin/polymyxinB NEO-POLYCIN OINT. (G) N    
oxytetracycline/polymyxin B TERRAMYCIN WITH POLYMYXIN OINT. (G) N    
oxytetracycline/polymyxin B TERAK OINT. (G) N    
sulfacetamide sodium SULFACETAMIDE SODIUM OINT. (G) N    
sulfacetamide sodium AK-SULF OINT. (G) N