Misc Ophthalmic Preparations
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 |
|---|---|---|---|---|---|---|
| cenegermin-bkbj | OXERVATE | DROPS | N | Pharmacy PA | Dec 03, 2020 | |
| dexamethasone | OZURDEX | IMPLANT | N | |||
| fluocinolone acetonide | ILUVIEN | IMPLANT | N | |||
| fluocinolone acetonide | RETISERT | IMPLANT | N | Jan 31, 2013 | ||
| pilocarpine HCl | VUITY | DROPS | N | |||
| pilocarpine HCl | PILOCARPINE HCL | DROPS | N | |||
| triamcinolone acetonide/PF | TRIESENCE | VIAL | N | |||
| acoltremon | TRYPTYR | DROPERETTE | ||||
| atropine sulfate | ATROPINE SULFATE | DROPS | ||||
| atropine sulfate | ISOPTO ATROPINE | DROPS | ||||
| atropine sulfate | ATROPINE SULFATE | OINT. (G) | ||||
| atropine sulfate/PF | ATROPINE SULFATE | DROPERETTE | ||||
| 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 | BSS | IRRIG SOLN | ||||
| balanced salt soln non-surg 3 | EYE-STREAM | IRRIG SOLN | ||||
| benoxinate HCl/fluorescein sod | FLUORESCEIN-BENOXINATE | DROPS | ||||
| carboxymethyl/gly/poly80/PF | REFRESH OPTIVE MEGA-3 PF | DROPERETTE | ||||
| carboxymethyl/gly/poly80/PF | REFRESH OPTIVE ADVANCED | DROPERETTE | ||||
| carboxymethyl/gly/poly80/PF | REFRESH DIGITAL PF | DROPERETTE | ||||
| carboxymethyl/gly/poly80/PF | REFRESH OPTIVE MEGA-3 PF | DROPS | ||||
| carboxymethyl/glycerin/poly80 | REFRESH OPTIVE ADVANCED | DROPS | ||||
| carboxymethyl/glycerin/poly80 | REFRESH DIGITAL | DROPS | ||||
| carboxymethylcell/glycerin/PF | REFRESH OPTIVE SENSITIVE | DROPERETTE | ||||
| carboxymethylcell/glycerin/PF | REFRESH RELIEVA PF | DROPERETTE | ||||
| carboxymethylcell/glycerin/PF | REFRESH TEARS PF | DROPS | ||||
| carboxymethylcell/glycerin/PF | REFRESH RELIEVA PF XTRA | DROPS | ||||
| carboxymethylcell/glycerin/PF | REFRESH RELIEVA PF | DROPS | ||||
| carboxymethylcellulos/glycerin | REFRESH RELIEVA | DROPS | ||||
| carboxymethylcellulos/glycerin | REFRESH OPTIVE | DROPS | ||||
| carboxymethylcellulos/glycerin | REFRESH OPTIVE | DROPS GEL | ||||
| carboxymethylcellulose sodium | CARBOXYMETHYLCELLULOSE SODIUM | DROPER GEL | ||||
| carboxymethylcellulose sodium | REFRESH CELLUVISC | DROPER GEL | ||||
| carboxymethylcellulose sodium | LUBRICANT EYE DROP | DROPERETTE | ||||
| carboxymethylcellulose sodium | CARBOXYMETHYLCELLULOSE SODIUM | DROPERETTE | ||||
| carboxymethylcellulose sodium | LUBRICANT EYE DROPS | DROPERETTE | ||||
| carboxymethylcellulose sodium | REFRESH PLUS | DROPERETTE | ||||
| carboxymethylcellulose sodium | REFRESH CONTACTS | DROPS | ||||
| carboxymethylcellulose sodium | REFRESH TEARS | DROPS | ||||
| carboxymethylcellulose sodium | CARBOXYMETHYLCELLULOSE SODIUM | DROPS | ||||
| carboxymethylcellulose sodium | LUBRICANT EYE DROP | DROPS | ||||
| carboxymethylcellulose sodium | CARBOXYMETHYLCELLULOSE SODIUM | DRP LQ GEL | ||||
| carboxymethylcellulose sodium | REFRESH LIQUIGEL | DRP LQ GEL | ||||
| chloroprocaine HCl/PF | IHEEZO | DROPER GEL | ||||
| cyclopentolate HCl | CYCLOGYL | DROPS | ||||
| cyclopentolate HCl | CYCLOPENTOLATE HCL | DROPS | ||||
| cyclopentolate/phenylephrine | CYCLOMYDRIL | DROPS | ||||
| cysteamine HCl | CYSTADROPS | DROPS | ||||
| cysteamine HCl | CYSTARAN | DROPS | ||||
| dextran 70/hypromellose/PF | BION TEARS | DROPERETTE | ||||
| dextran 70/hypromellose/PF | GENTEAL TEARS | DROPERETTE | ||||
| dextran 70/hypromellose/PF | TEARS NATURALE FREE | DROPERETTE | ||||
| dextran/hypromellose/glycerin | TEARS NATURALE FORTE | DROPS | ||||
| dextran/hypromellose/glycerin | GENTEAL TEARS | DROPS | ||||
| dextran/hypromellose/glycerin | ARTIFICIAL TEARS | DROPS | ||||
| epinephryl borate | EPINAL | DROPS | ||||
| eyelid cleanser combination 9 | SYSTANE | TOWELETTE | ||||
| fluocinolone acetonide | YUTIQ | IMPLANT | ||||
| ganciclovir | ZIRGAN | GEL (GRAM) | ||||
| gelatin | GELFILM | EACH | ||||
| hyaluronate sodium | BIOLON | SYRINGE | ||||
| hyaluronate sodium | HEALON5 PRO | SYRINGE | ||||
| hydroxypropyl cellulose | LACRISERT | INSERT | ||||
| hypromellose | TEARS LUBRICANT EYE DROP | DROPS | ||||
| hypromellose | GENTEAL TEARS SEVERE | GEL (GRAM) | ||||
| hypromellose | SYSTANE GEL | GEL (GRAM) | ||||
| lidocaine HCl/PF | AKTEN | GEL (ML) | ||||
| lotilaner | XDEMVY | DROPS | ||||
| mineral oil/petrolatum,white | LUBRIFRESH PM | OINT. (G) | ||||
| mineral oil/petrolatum,white | GENTEAL TEARS SEVERE | OINT. (G) | ||||
| mineral oil/petrolatum,white | NIGHTTIME RELIEF LUBRICANT EYE | 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) | ||||
| mitomycin | MITOSOL | KIT | ||||
| naphazoline HCl | NAPHAZOLINE HCL | DROPS | ||||
| naphazoline HCl/pheniramine | NAPHCON-A | DROPS | ||||
| naphazoline HCl/pheniramine | OPCON-A | DROPS | ||||
| peg 400/hypromellose/glycerin | DRY EYE RELIEF | DROPS | ||||
| phentolamine mesylate/PF | RYZUMVI | DROPERETTE | ||||
| phenylephrine HCl | PHENYLEPHRINE HCL | DROPS | ||||
| phenylephrine/ketorolac | OMIDRIA | VIAL | ||||
| polyethylene glycol 400 | DRY EYE RELIEF | DROPS | ||||
| polyvinyl alcohol | POLYVINYL ALCOHOL | DROPS | ||||
| polyvinyl alcohol | LIQUIFILM TEARS | DROPS | ||||
| polyvinyl alcohol/povidone | MURINE | DROPS | ||||
| polyvinyl alcohol/povidone | FRESHKOTE | DROPS | ||||
| polyvinyl alcohol/povidone | ARTIFICIAL TEARS | DROPS | ||||
| polyvinyl alcohol/povidone/PF | REFRESH CLASSIC | DROPERETTE | ||||
| povidone-iodine | BETADINE | SOLUTION | ||||
| povidone/PF | IVIZIA | DROPER GEL | ||||
| proparacaine HCl | PROPARACAINE HCL | DROPS | ||||
| proparacaine HCl | ALCAINE | DROPS | ||||
| propylene glycol | SYSTANE BALANCE | DROPS | ||||
| propylene glycol | SYSTANE COMPLETE | DROPS | ||||
| propylene glycol | LUBRICANT EYE DROP | DROPS | ||||
| propylene glycol/peg 400 | SYSTANE ULTRA | DROPS | ||||
| propylene glycol/peg 400 | LUBRICANT EYE | DROPS | ||||
| propylene glycol/peg 400 | LUBRICATING EYE | DROPS | ||||
| propylene glycol/peg 400 | ULTRA LUBRICANT EYE | DROPS | ||||
| propylene glycol/peg 400 | SYSTANE | DROPS | ||||
| propylene glycol/peg 400 | GENTEAL TEARS SEVERE | DROPS GEL | ||||
| propylene glycol/peg 400 | SYSTANE GEL | DROPS GEL | ||||
| propylene glycol/peg 400/PF | SYSTANE | DROPERETTE | ||||
| propylene glycol/peg 400/PF | SYSTANE HYDRATION PF | DROPERETTE | ||||
| propylene glycol/peg 400/PF | LUBRICANT EYE | DROPERETTE | ||||
| propylene glycol/peg 400/PF | SYSTANE ULTRA | DROPERETTE | ||||
| propylene glycol/peg 400/PF | ULTRA LUBRICANT EYE | DROPERETTE | ||||
| propylene glycol/peg 400/PF | SYSTANE HYDRATION PF | DROPS | ||||
| propylene glycol/peg 400/PF | SYSTANE ULTRA PF | DROPS | ||||
| propylene glycol/PF | SYSTANE COMPLETE PF | DROPERETTE | ||||
| propylene glycol/PF | SYSTANE PRO PF | DROPS | ||||
| propylene glycol/PF | SYSTANE COMPLETE PF | DROPS | ||||
| revakinagene taroretcel-lwey | ENCELTO | IMPLANT | ||||
| riboflavin 5-phos/20 % dextran | PHOTREXA CROSS-LINKING | CMB DPVDP | ||||
| riboflavin 5-phos/20 % dextran | PHOTREXA VISCOUS | DROPS VISC | ||||
| riboflavin 5-phosphate sod(B2) | PHOTREXA | DROPS | ||||
| riboflavin 5-phosphate sod(B2) | EPIOXA | KIT | ||||
| sod borate/boric ac/water/NaCl | EYE WASH | IRRIG SOLN | ||||
| sodium chloride | MURO-128 | DROPS | ||||
| sodium chloride | SODIUM CHLORIDE | DROPS | ||||
| sodium chloride | SODIUM CHLORIDE | OINT. (G) | ||||
| sodium chloride | MURO-128 | OINT. (G) | ||||
| sodium chloride | LENS PLUS | SPRAY | ||||
| tetracaine HCl | TETRACAINE HCL | DROPS | ||||
| tetracaine HCl/PF | TETRACAINE HCL | DROPS | ||||
| triamcinolone acetonide/PF | XIPERE | VIAL | ||||
| trifluridine | TRIFLURIDINE | DROPS | ||||
| tropicamide | TROPICAMIDE | DROPS | ||||
| tropicamide | MYDRIACYL | DROPS | ||||
| tyloxapol | ENUCLENE | DROPS | ||||
| verteporfin | VISUDYNE | VIAL | ||||
| voretigene neparvovec-rzyl | LUXTURNA | VIAL | Pharmacy PA | BILL FFS | Mar 22, 2018 |