Antibiotic-Steroids, 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 |
|---|---|---|---|---|---|
| neomycin/polymyxin B/dexametha | MAXITROL | DROPS SUSP | Y | ||
| neomycin/polymyxin B/dexametha | NEOMYCIN-POLYMYXIN-DEXAMETH | DROPS SUSP | Y | ||
| neomycin/polymyxin B/dexametha | NEOMYCIN-POLYMYXIN-DEXAMETH | OINT. (G) | Y | ||
| neomycin/polymyxin B/dexametha | MAXITROL | OINT. (G) | Y | ||
| tobramycin/dexamethasone | TOBRADEX ST | DROPS SUSP | Y | ||
| tobramycin/dexamethasone | TOBRADEX | DROPS SUSP | Y | ||
| tobramycin/dexamethasone | TOBRAMYCIN-DEXAMETHASONE | 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/dexamethasone sod ph | NEOMYCIN W/DEXAMETHASONE | DROPS | N | ||
| neomycin/polymyxin B/hydrocort | NEOMYCIN-POLYMYXIN-HC | DROPS SUSP | N | ||
| sulfacetamide/prednisolone sp | SULFACETAMIDE-PREDNISOLONE | DROPS | N | ||
| tobramycin/lotepred etab | ZYLET | DROPS SUSP | N | ||
| neomycin/polymyxin B/dexametha | MAXITROL | OINT. (G) |