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