Antibiotics, 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 & Updates |
|---|---|---|---|---|---|
| bacitracin/polymyxin B sulfate | POLYCIN | OINT. (G) | Y | ||
| bacitracin/polymyxin B sulfate | BACITRACIN-POLYMYXIN | OINT. (G) | Y | ||
| ciprofloxacin HCl | CIPROFLOXACIN HCL | 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 | ||
| moxifloxacin HCl | MOXIFLOXACIN | DROPS | Y | ||
| moxifloxacin HCl | VIGAMOX | DROPS | Y | ||
| natamycin | NATACYN | DROPS SUSP | Y | ||
| neomycin/polymyxn B/gramicidin | NEOMYCIN/POLYMYXIN/GRAMICIDIN | DROPS | Y | ||
| neomycin/polymyxn B/gramicidin | NEOMYCIN-POLYMYXIN-GRAMICIDIN | DROPS | Y | ||
| neomycin/polymyxn B/gramicidin | NEOPTIC | DROPS | Y | ||
| ofloxacin | OCUFLOX | DROPS | Y | ||
| ofloxacin | OFLOXACIN | DROPS | Y | ||
| polymyxin B sulf/trimethoprim | POLYMYXIN B SUL-TRIMETHOPRIM | DROPS | Y | ||
| sulfacetamide sodium | ISOPTO CETAMIDE | DROPS | Y | ||
| sulfacetamide sodium | SULFACETAMIDE SODIUM | DROPS | Y | ||
| tobramycin | TOBRAMYCIN | DROPS | Y | ||
| tobramycin | TOBREX | OINT. (G) | Y | ||
| azithromycin | AZASITE | DROPS | N | ||
| bacitracin | BACITRACIN | OINT. (G) | N | ||
| besifloxacin HCl | BESIVANCE | DROPS SUSP | N | ||
| chloramphenicol | CHLORAMPHENICOL | OINT. (G) | N | ||
| gatifloxacin | GATIFLOXACIN | DROPS | N | ||
| neomycin/bacitracin/polymyxinB | NEO-POLYCIN | OINT. (G) | N | ||
| neomycin/bacitracin/polymyxinB | NEOMYCIN-BACITRACIN-POLYMYXIN | OINT. (G) | N | ||
| oxytetracycline/polymyxin B | TERRAMYCIN WITH POLYMYXIN | OINT. (G) | N | ||
| sulfacetamide sodium | SULFACETAMIDE SODIUM | OINT. (G) | N | ||
| moxifloxacin HCl | MOXIFLOXACIN | DROPS |