Misc Opthalmic Preparations

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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 but eligible patients will encounter a co-pay at the pharmacy.
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
dexamethasone OZURDEX IMPLANT N    
fluocinolone acetonide ILUVIEN IMPLANT N    
fluocinolone acetonide RETISERT IMPLANT N   Jan 31, 2013
triamcinolone acetonide/PF TRIESENCE VIAL N    
atropine sulfate ATROPINE SULFATE DROPS    
atropine sulfate ISOPTO ATROPINE DROPS    
atropine sulfate ATROPINE SULFATE OINT. (G)    
balanced salt irrig soln no.1 BSS PLUS IRRIG SOLN    
balanced salt irrig soln no.1 AMO ENDOSOL EXTRA IRRIG SOLN    
balanced salt irrig soln no.2 AMO ENDOSOL IRRIG SOLN    
balanced salt irrig soln no.2 BALANCED SALT IRRIG SOLN    
balanced salt irrig soln no.2 BSS IRRIG SOLN    
balanced salt soln non-surg 3 EYE-STREAM IRRIG SOLN    
brimonidine tartrate LUMIFY DROPS    
carboxymethyl/gly/poly80/PF REFRESH OPTIVE ADVANCED DROPERETTE    
carboxymethyl/gly/poly80/PF REFRESH OPTIVE MEGA-3 DROPERETTE    
carboxymethyl/glycerin/poly80 REFRESH OPTIVE ADVANCED DROPS    
carboxymethylcell/glycerin/PF REFRESH OPTIVE SENSITIVE DROPERETTE    
carboxymethylcellulos/glycerin REFRESH RELIEVA DROPS    
carboxymethylcellulos/glycerin REFRESH REPAIR DROPS    
carboxymethylcellulos/glycerin REFRESH OPTIVE DROPS    
carboxymethylcellulos/glycerin REFRESH OPTIVE DROPS GEL    
carboxymethylcellulose sodium REFRESH CELLUVISC DROPER GEL    
carboxymethylcellulose sodium REFRESH PLUS DROPERETTE    
carboxymethylcellulose sodium LUBRICATING PLUS DROPERETTE    
carboxymethylcellulose sodium REFRESH CONTACTS DROPS    
carboxymethylcellulose sodium REFRESH TEARS DROPS    
carboxymethylcellulose sodium LUBRICANT EYE DROP DROPS    
carboxymethylcellulose sodium REFRESH LIQUIGEL DRP LQ GEL    
cenegermin-bkbj OXERVATE DROPS PA Document  
cromolyn sodium CROMOLYN SODIUM DROPS    
cyclopentolate HCl CYCLOGYL DROPS    
cyclopentolate HCl CYCLOPENTOLATE HCL DROPS    
cyclopentolate/phenylephrine CYCLOMYDRIL DROPS    
cyclosporine CEQUA DROPERETTE    
cyclosporine RESTASIS DROPERETTE    
cyclosporine RESTASIS MULTIDOSE DROPS    
cysteamine HCl CYSTARAN DROPS    
dexamethasone/PF DEXYCU VIAL    
dextran 70/hypromellose GENTEAL TEARS DROPS    
dextran 70/hypromellose NATURAL BALANCE TEARS DROPS    
dextran 70/hypromellose NATURE'S TEARS DROPS    
dextran 70/hypromellose/PF GENTEAL TEARS DROPERETTE    
dextran 70/hypromellose/PF BION TEARS DROPERETTE    
dextran 70/hypromellose/PF TEARS NATURALE FREE DROPERETTE    
dextran/hypromellose/glycerin GENTEAL TEARS DROPS    
dextran/hypromellose/glycerin TEARS NATURALE FORTE DROPS    
epinephryl borate EPINAL DROPS    
eyelid cleanser combination 9 SYSTANE TOWELETTE    
fluocinolone acetonide YUTIQ IMPLANT    
ganciclovir ZIRGAN GEL (GRAM)    
gelatin GELFILM EACH    
hyaluronate sodium AMVISC SYRINGE    
hyaluronate sodium AMVISC PLUS SYRINGE    
hyaluronate sodium BIOLON SYRINGE    
hyaluronate sodium VITRAX SYRINGE    
hydroxyamphetamine/tropicamide PAREMYD DROPS    
hydroxypropyl cellulose LACRISERT INSERT    
hypromellose GONAK DROPS    
hypromellose ISOPTO TEARS DROPS    
hypromellose GENTEAL TEARS SEVERE GEL (GRAM)    
hypromellose SYSTANE GEL GEL (GRAM)    
lidocaine HCl/PF AKTEN GEL (ML)    
lifitegrast XIIDRA DROPERETTE   Jan 26, 2017
lodoxamide tromethamine ALOMIDE DROPS    
mineral oil/petrolatum,white PURALUBE OINT. (G)    
mineral oil/petrolatum,white REFRESH LACRI-LUBE OINT. (G)    
mineral oil/petrolatum,white REFRESH P.M. OINT. (G)    
mineral oil/petrolatum,white SYSTANE OINT. (G)    
mineral oil/petrolatum,white LUBRIFRESH PM OINT. (G)    
mineral oil/petrolatum,white ARTIFICIAL TEARS OINT. (G)    
mineral oil/petrolatum,white LUBRICANT PM OINT. (G)    
naphazoline HCl NAPHAZOLINE HCL DROPS    
naphazoline HCl/glycerin REDNESS RELIEF DROPS    
naphazoline HCl/glycerin EYE DROPS REDNESS RELIEF DROPS    
naphazoline HCl/pheniramine NAPHCON-A DROPS    
naphazoline HCl/pheniramine EYE ALLERGY RELIEF DROPS    
naphazoline HCl/zinc sulfate CLEAR EYES ACR DROPS    
nedocromil sodium ALOCRIL DROPS    
ocriplasmin/PF JETREA VIAL    
peg 400/hypromellose/glycerin DRY EYE RELIEF DROPS    
phenylephrine HCl PHENYLEPHRINE HCL DROPS    
phenylephrine/ketorolac OMIDRIA VIAL    
polyvinyl alcohol POLYVINYL ALCOHOL DROPS    
polyvinyl alcohol LIQUITEARS DROPS    
polyvinyl alcohol LIQUIFILM TEARS DROPS    
polyvinyl alcohol ARTIFICIAL TEARS DROPS    
polyvinyl alcohol/povidone ARTIFICIAL TEARS DROPS    
polyvinyl alcohol/povidone MURINE DROPS    
polyvinyl alcohol/povidone/PF REFRESH CLASSIC DROPERETTE    
povidone-iodine BETADINE SOLUTION    
proparacaine HCl ALCAINE DROPS    
proparacaine HCl PROPARACAINE HCL DROPS    
propylene glycol SYSTANE COMPLETE DROPS    
propylene glycol SYSTANE BALANCE DROPS    
propylene glycol/peg 400 LUBRICANT EYE DROPS    
propylene glycol/peg 400 LUBRICATING EYE DROPS    
propylene glycol/peg 400 LUBRICATING RELIEF DROPS    
propylene glycol/peg 400 LUBRICATING TEARS DROPS    
propylene glycol/peg 400 SYSTANE ULTRA DROPS    
propylene glycol/peg 400 ULTRA LUBRICANT EYE DROPS    
propylene glycol/peg 400 SYSTANE DROPS    
propylene glycol/peg 400 SYSTANE GEL DROPS GEL    
propylene glycol/peg 400/PF LUBRICANT EYE DROPERETTE    
propylene glycol/peg 400/PF SYSTANE DROPERETTE    
propylene glycol/peg 400/PF SYSTANE ULTRA DROPERETTE    
sod borate/boric ac/water/NaCl EYE WASH IRRIG SOLN    
sod borate/boric ac/water/NaCl EYE IRRIGATING SOLUTION IRRIG SOLN    
sodium chloride MURO-128 DROPS    
sodium chloride SODIUM CHLORIDE DROPS    
sodium chloride MURO-128 OINT. (G)    
sodium chloride SODIUM CHLORIDE OINT. (G)    
sodium chloride LENS PLUS SPRAY    
sodium/potassium/sod chl EYE WASH DROPS    
tetracaine HCl TETRACAINE HCL DROPS    
tetracaine HCl AK-T-CAINE PF DROPS    
tetracaine HCl/PF TETRACAINE HCL DROPS    
tetrahydroz/dext 70/peg 400/pv EYE DROPS DROPS    
tetrahydroz/dext 70/peg 400/pv EYE DROPS ADVANCED RELIEF DROPS    
tetrahydrozoline HCl EYE DROPS DROPS    
tetrahydrozoline HCl MURINE PLUS DROPS    
tetrahydrozoline HCl STERILE EYE DROPS DROPS    
tetrahydrozoline HCl OPTI-CLEAR DROPS    
trifluridine TRIFLURIDINE DROPS    
trifluridine VIROPTIC DROPS    
tropicamide MYDRIACYL DROPS    
tropicamide TROPICAMIDE DROPS    
tyloxapol ENUCLENE DROPS    
verteporfin VISUDYNE VIAL    
voretigene neparvovec-rzyl LUXTURNA VIAL PA Document Mar 22, 2018