Glaucoma Drugs
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| betaxolol HCl | BETAXOLOL HCL | DROPS | Y | N | ||
| brimonidine tartrate | ALPHAGAN P | DROPS | Y | N | ||
| brimonidine tartrate | BRIMONIDINE TARTRATE | DROPS | Y | N | ||
| brinzolamide | BRINZOLAMIDE | DROPS SUSP | Y | N | ||
| brinzolamide | AZOPT | DROPS SUSP | Y | N | ||
| carteolol HCl | CARTEOLOL HCL | DROPS | Y | N | ||
| dorzolamide HCl/timolol maleat | DORZOLAMIDE-TIMOLOL | DROPS | Y | N | ||
| dorzolamide HCl/timolol maleat | COSOPT | DROPS | Y | N | ||
| dorzolamide/timolol/PF | DORZOLAMIDE-TIMOLOL | DROPERETTE | Y | N | ||
| dorzolamide/timolol/PF | COSOPT PF | DROPERETTE | Y | N | ||
| latanoprost | LATANOPROST | DROPS | Y | N | ||
| latanoprost | XALATAN | DROPS | Y | N | ||
| pilocarpine HCl | PILOCARPINE HCL | DROPS | Y | N | ||
| timolol maleate | TIMOLOL MALEATE | DROPS | Y | N | ||
| timolol maleate | TIMOPTIC | DROPS | Y | N | ||
| travoprost | TRAVATAN Z | DROPS | Y | N | ||
| travoprost | TRAVOPROST | DROPS | Y | N | ||
| acetylcholine chloride | MIOCHOL-E | KIT | N | N | ||
| apraclonidine HCl | IOPIDINE | DROPERETTE | N | N | ||
| apraclonidine HCl | APRACLONIDINE HCL | DROPS | N | N | ||
| betaxolol HCl | BETOPTIC S | DROPS SUSP | N | N | ||
| bimatoprost | BIMATOPROST | DROPS | N | N | ||
| bimatoprost | LUMIGAN | DROPS | N | N | ||
| brimonidine tartrate/timolol | BRIMONIDINE TARTRATE-TIMOLOL | DROPS | N | N | ||
| brimonidine tartrate/timolol | COMBIGAN | DROPS | N | N | ||
| brinzolamide/brimonidine tart | SIMBRINZA | DROPS SUSP | N | N | ||
| carbachol | MIOSTAT | VIAL | N | N | ||
| dorzolamide HCl | DORZOLAMIDE HCL | DROPS | N | N | ||
| dorzolamide HCl | TRUSOPT | DROPS | N | N | ||
| latanoprost/PF | IYUZEH | DROPERETTE | N | N | ||
| latanoprostene bunod | VYZULTA | DROPS | N | N | ||
| levobunolol HCl | LEVOBUNOLOL HCL | DROPS | N | N | ||
| netarsudil mesylat/latanoprost | ROCKLATAN | DROPS | N | N | ||
| netarsudil mesylate | RHOPRESSA | DROPS | N | N | ||
| tafluprost/PF | TAFLUPROST | DROPERETTE | N | N | ||
| tafluprost/PF | ZIOPTAN | DROPERETTE | N | N | ||
| timolol | BETIMOL | DROPS | N | N | ||
| timolol | TIMOLOL | DROPS | N | N | ||
| timolol maleate | TIMOLOL MALEATE | DROP DAILY | N | N | ||
| timolol maleate | ISTALOL | DROP DAILY | N | N | ||
| timolol maleate | TIMOLOL MALEATE | SOL-GEL | N | N | ||
| timolol maleate | TIMOPTIC-XE | SOL-GEL | N | N | ||
| timolol maleate/PF | TIMOLOL MALEATE | DROPERETTE | N | N | ||
| timolol maleate/PF | TIMOPTIC OCUDOSE | DROPERETTE | N | N | ||
| bimatoprost | DURYSTA | IMPLANT | N | |||
| travoprost | IDOSE TR | IMPLANT | N |