Ophthalmic Medications for Allergies

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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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
azelastine HCl AZELASTINE HCL DROPS Y    
cromolyn sodium CROMOLYN SODIUM DROPS Y    
olopatadine HCl RETAINE ALLERGY DROPS Y    
olopatadine HCl EYE ALLERGY ITCH RELIEF DROPS Y    
olopatadine HCl EYE ALLERGY ITCH-REDNESS RLF DROPS Y    
olopatadine HCl OLOPATADINE HCL DROPS Y    
olopatadine HCl ADVANCED EYE RELIEF DROPS Y    
olopatadine HCl PATADAY TWICE DAILY RELIEF DROPS Y    
olopatadine HCl PATADAY ONCE DAILY RELIEF DROPS Y    
olopatadine HCl OLOPATADINE HCL DROPS Y    
olopatadine HCl EYE ALLERGY ITCH-REDNESS RLF DROPS Y    
olopatadine HCl EYE ALLERGY ITCH RELIEF DROPS Y    
alcaftadine LASTACAFT ONCE DAILY RELIEF DROPS N    
bepotastine besilate BEPREVE DROPS N    
bepotastine besilate BEPOTASTINE BESILATE DROPS N    
brimonidine tartrate LUMIFY DROPS N    
brimonidine tartrate/PF LUMIFY DROPERETTE N    
cetirizine HCl ZERVIATE DROPERETTE N    
epinastine HCl EPINASTINE HCL DROPS N    
ketotifen fumarate ZADITOR DROPS N    
ketotifen fumarate KETOTIFEN FUMARATE DROPS N    
ketotifen fumarate EYE ITCH RELIEF DROPS N    
ketotifen fumarate CHILDREN'S ALAWAY DROPS N    
ketotifen fumarate ALAWAY DROPS N    
naphazoline HCl/glycerin REDNESS RELIEF DROPS N    
naphazoline HCl/glycerin MAX REDNESS RELIEF DROPS N    
naphazoline HCl/zinc sulfate CLEAR EYES ACR DROPS N    
olopatadine HCl EYE ALLERGY ITCH RELIEF DROPS N    
olopatadine HCl PATADAY ONCE DAILY RELIEF DROPS N    
olopatadine HCl OLOPATADINE HCL DROPS N    
tetrahydroz/dext 70/peg 400/pv EYE DROPS ADVANCED RELIEF DROPS N    
tetrahydroz/dext 70/peg 400/pv EYE DROPS MOISTURIZING RELIEF DROPS N    
tetrahydroz/dext 70/peg 400/pv EYE DROPS DROPS N    
tetrahydrozoline HCl MURINE PLUS DROPS N    
tetrahydrozoline HCl EYE DROPS DROPS N    
tetrahydrozoline HCl/zinc sulf EYE DROPS SEASONAL RELIEF DROPS N    
tetrahydrozoline HCl/zinc sulf EYE DROPS IRRITATION RELIEF DROPS N    
tetrahydrozoline/zinc/peg 400 MULTI-SYMPTOM RELIEF EYE DROPS N    
tetrahydrozoline/polyethyl gly EYE DROPS DROPS    
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