Ophthalmic Medications for Allergies
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 |
|---|---|---|---|---|---|---|
| azelastine HCl | AZELASTINE HCL | DROPS | Y | N | ||
| cromolyn sodium | CROMOLYN SODIUM | DROPS | Y | N | ||
| olopatadine HCl | OLOPATADINE HCL | DROPS | Y | N | ||
| olopatadine HCl | PATADAY ONCE DAILY RELIEF | DROPS | Y | N | ||
| olopatadine HCl | PATADAY TWICE DAILY RELIEF | DROPS | Y | N | ||
| olopatadine HCl | EYE ALLERGY ITCH-REDNESS RLF | DROPS | Y | N | ||
| olopatadine HCl | EYE ALLERGY ITCH RELIEF | DROPS | Y | N | ||
| olopatadine HCl | ADVANCED EYE RELIEF | DROPS | Y | N | ||
| olopatadine HCl | EYE ALLERGY ITCH-REDNESS RLF | DROPS | Y | N | ||
| olopatadine HCl | EYE ALLERGY ITCH RELIEF | DROPS | Y | N | ||
| olopatadine HCl | RETAINE ALLERGY | DROPS | Y | N | ||
| olopatadine HCl | OLOPATADINE HCL | DROPS | Y | N | ||
| alcaftadine | LASTACAFT ONCE DAILY RELIEF | DROPS | N | N | ||
| bepotastine besilate | BEPOTASTINE BESILATE | DROPS | N | N | ||
| bepotastine besilate | BEPREVE | DROPS | N | N | ||
| brimonidine tartrate | LUMIFY | DROPS | N | N | ||
| brimonidine tartrate/PF | LUMIFY | DROPERETTE | N | N | ||
| cetirizine HCl | ZERVIATE | DROPERETTE | N | N | ||
| epinastine HCl | EPINASTINE HCL | DROPS | N | N | ||
| ketotifen fumarate | EYE ITCH RELIEF | DROPS | N | N | ||
| ketotifen fumarate | ZADITOR | DROPS | N | N | ||
| ketotifen fumarate | CHILDREN'S ALAWAY | DROPS | N | N | ||
| ketotifen fumarate | KETOTIFEN FUMARATE | DROPS | N | N | ||
| ketotifen fumarate | ALAWAY | DROPS | N | N | ||
| naphazoline HCl/glycerin | MAX REDNESS RELIEF | DROPS | N | N | ||
| naphazoline HCl/glycerin | REDNESS RELIEF | DROPS | N | N | ||
| naphazoline HCl/zinc sulfate | CLEAR EYES ACR | DROPS | N | N | ||
| olopatadine HCl | PATADAY ONCE DAILY RELIEF | DROPS | N | N | ||
| olopatadine HCl | OLOPATADINE HCL | DROPS | N | N | ||
| tetrahydroz/dext 70/peg 400/pv | EYE DROPS | DROPS | N | N | ||
| tetrahydroz/dext 70/peg 400/pv | EYE DROPS ADVANCED RELIEF | DROPS | N | N | ||
| tetrahydroz/dext 70/peg 400/pv | EYE DROPS MOISTURIZING RELIEF | DROPS | N | N | ||
| tetrahydrozoline HCl | EYE DROPS | DROPS | N | N | ||
| tetrahydrozoline HCl | MURINE PLUS | DROPS | N | N | ||
| tetrahydrozoline HCl/zinc sulf | EYE DROPS IRRITATION RELIEF | DROPS | N | N | ||
| tetrahydrozoline HCl/zinc sulf | EYE DROPS SEASONAL RELIEF | DROPS | N | N | ||
| tetrahydrozoline/zinc/peg 400 | MULTI-SYMPTOM RELIEF EYE | DROPS | N | N | ||
| tetrahydrozoline/polyethyl gly | EYE DROPS | DROPS | N |