Misc Ophthalmic 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.
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
cenegermin-bkbj OXERVATE DROPS N Pharmacy PA N Dec 03, 2020
dexamethasone OZURDEX IMPLANT N   N  
fluocinolone acetonide RETISERT IMPLANT N   N Jan 31, 2013
fluocinolone acetonide ILUVIEN IMPLANT N   N  
pilocarpine HCl PILOCARPINE HCL DROPS N   N  
pilocarpine HCl VUITY DROPS N   N  
triamcinolone acetonide/PF TRIESENCE VIAL N   N  
acoltremon TRYPTYR DROPERETTE   N  
atropine sulfate ATROPINE SULFATE DROPS   N  
atropine sulfate ISOPTO ATROPINE DROPS   N  
atropine sulfate ATROPINE SULFATE OINT. (G)   N  
atropine sulfate/PF ATROPINE SULFATE DROPERETTE   N  
balanced salt irrig soln no.1 AMO ENDOSOL EXTRA IRRIG SOLN   N  
balanced salt irrig soln no.1 BSS PLUS IRRIG SOLN   N  
balanced salt irrig soln no.2 AMO ENDOSOL IRRIG SOLN   N  
balanced salt irrig soln no.2 BSS IRRIG SOLN   N  
balanced salt soln non-surg 3 EYE-STREAM IRRIG SOLN   N  
benoxinate HCl/fluorescein sod FLUORESCEIN-BENOXINATE DROPS   N  
carboxymethyl/gly/poly80/PF REFRESH DIGITAL PF DROPERETTE   N  
carboxymethyl/gly/poly80/PF REFRESH OPTIVE ADVANCED DROPERETTE   N  
carboxymethyl/gly/poly80/PF REFRESH OPTIVE MEGA-3 PF DROPERETTE   N  
carboxymethyl/gly/poly80/PF REFRESH OPTIVE MEGA-3 PF DROPS   N  
carboxymethyl/glycerin/poly80 REFRESH OPTIVE ADVANCED DROPS   N  
carboxymethyl/glycerin/poly80 REFRESH DIGITAL DROPS   N  
carboxymethylcell/glycerin/PF REFRESH OPTIVE SENSITIVE DROPERETTE   N  
carboxymethylcell/glycerin/PF REFRESH RELIEVA PF DROPERETTE   N  
carboxymethylcell/glycerin/PF REFRESH RELIEVA PF DROPS   N  
carboxymethylcell/glycerin/PF REFRESH RELIEVA PF XTRA DROPS   N  
carboxymethylcell/glycerin/PF REFRESH TEARS PF DROPS   N  
carboxymethylcellulos/glycerin REFRESH OPTIVE DROPS   N  
carboxymethylcellulos/glycerin REFRESH RELIEVA DROPS   N  
carboxymethylcellulos/glycerin REFRESH OPTIVE DROPS GEL   N  
carboxymethylcellulose sodium REFRESH CELLUVISC DROPER GEL   N  
carboxymethylcellulose sodium CARBOXYMETHYLCELLULOSE SODIUM DROPER GEL   N  
carboxymethylcellulose sodium CARBOXYMETHYLCELLULOSE SODIUM DROPERETTE   N  
carboxymethylcellulose sodium LUBRICANT EYE DROP DROPERETTE   N  
carboxymethylcellulose sodium LUBRICANT EYE DROPS DROPERETTE   N  
carboxymethylcellulose sodium REFRESH PLUS DROPERETTE   N  
carboxymethylcellulose sodium CARBOXYMETHYLCELLULOSE SODIUM DROPS   N  
carboxymethylcellulose sodium REFRESH CONTACTS DROPS   N  
carboxymethylcellulose sodium REFRESH TEARS DROPS   N  
carboxymethylcellulose sodium LUBRICANT EYE DROP DROPS   N  
carboxymethylcellulose sodium REFRESH LIQUIGEL DRP LQ GEL   N  
carboxymethylcellulose sodium CARBOXYMETHYLCELLULOSE SODIUM DRP LQ GEL   N  
chloroprocaine HCl/PF IHEEZO DROPER GEL   N  
cyclopentolate HCl CYCLOGYL DROPS   N  
cyclopentolate HCl CYCLOPENTOLATE HCL DROPS   N  
cyclopentolate/phenylephrine CYCLOMYDRIL DROPS   N  
cysteamine HCl CYSTADROPS DROPS   N  
cysteamine HCl CYSTARAN DROPS   N  
dextran 70/hypromellose/PF TEARS NATURALE FREE DROPERETTE   N  
dextran 70/hypromellose/PF BION TEARS DROPERETTE   N  
dextran 70/hypromellose/PF GENTEAL TEARS DROPERETTE   N  
dextran/hypromellose/glycerin ARTIFICIAL TEARS DROPS   N  
dextran/hypromellose/glycerin GENTEAL TEARS DROPS   N  
dextran/hypromellose/glycerin TEARS NATURALE FORTE DROPS   N  
epinephryl borate EPINAL DROPS   N  
eyelid cleanser combination 9 SYSTANE TOWELETTE   N  
fluocinolone acetonide YUTIQ IMPLANT   N  
ganciclovir ZIRGAN GEL (GRAM)   N  
gelatin GELFILM EACH   N  
hyaluronate sodium BIOLON SYRINGE   N  
hyaluronate sodium HEALON5 PRO SYRINGE   N  
hydroxypropyl cellulose LACRISERT INSERT   N  
hypromellose TEARS LUBRICANT EYE DROP DROPS   N  
hypromellose GENTEAL TEARS SEVERE GEL (GRAM)   N  
hypromellose SYSTANE GEL GEL (GRAM)   N  
lidocaine HCl/PF AKTEN GEL (ML)   N  
lotilaner XDEMVY DROPS   N  
mineral oil/petrolatum,white GENTEAL TEARS SEVERE OINT. (G)   N  
mineral oil/petrolatum,white LUBRIFRESH PM OINT. (G)   N  
mineral oil/petrolatum,white NIGHTTIME RELIEF LUBRICANT EYE OINT. (G)   N  
mineral oil/petrolatum,white REFRESH LACRI-LUBE OINT. (G)   N  
mineral oil/petrolatum,white REFRESH P.M. OINT. (G)   N  
mineral oil/petrolatum,white SYSTANE OINT. (G)   N  
mitomycin MITOSOL KIT   N  
naphazoline HCl NAPHAZOLINE HCL DROPS   N  
naphazoline HCl/pheniramine OPCON-A DROPS   N  
naphazoline HCl/pheniramine NAPHCON-A DROPS   N  
peg 400/hypromellose/glycerin DRY EYE RELIEF DROPS   N  
phentolamine mesylate/PF RYZUMVI DROPERETTE   N  
phenylephrine HCl PHENYLEPHRINE HCL DROPS   N  
phenylephrine/ketorolac OMIDRIA VIAL   N  
polyethylene glycol 400 DRY EYE RELIEF DROPS   N  
polyvinyl alcohol LIQUIFILM TEARS DROPS   N  
polyvinyl alcohol POLYVINYL ALCOHOL DROPS   N  
polyvinyl alcohol/povidone FRESHKOTE DROPS   N  
polyvinyl alcohol/povidone ARTIFICIAL TEARS DROPS   N  
polyvinyl alcohol/povidone MURINE DROPS   N  
polyvinyl alcohol/povidone/PF REFRESH CLASSIC DROPERETTE   N  
povidone-iodine BETADINE SOLUTION   N  
proparacaine HCl ALCAINE DROPS   N  
proparacaine HCl PROPARACAINE HCL DROPS   N  
propylene glycol LUBRICANT EYE DROP DROPS   N  
propylene glycol SYSTANE BALANCE DROPS   N  
propylene glycol SYSTANE COMPLETE DROPS   N  
propylene glycol/peg 400 SYSTANE DROPS   N  
propylene glycol/peg 400 SYSTANE ULTRA DROPS   N  
propylene glycol/peg 400 ULTRA LUBRICANT EYE DROPS   N  
propylene glycol/peg 400 LUBRICANT EYE DROPS   N  
propylene glycol/peg 400 LUBRICATING EYE DROPS   N  
propylene glycol/peg 400 SYSTANE GEL DROPS GEL   N  
propylene glycol/peg 400 GENTEAL TEARS SEVERE DROPS GEL   N  
propylene glycol/peg 400/PF SYSTANE ULTRA DROPERETTE   N  
propylene glycol/peg 400/PF LUBRICANT EYE DROPERETTE   N  
propylene glycol/peg 400/PF SYSTANE DROPERETTE   N  
propylene glycol/peg 400/PF ULTRA LUBRICANT EYE DROPERETTE   N  
propylene glycol/peg 400/PF SYSTANE HYDRATION PF DROPERETTE   N  
propylene glycol/peg 400/PF SYSTANE HYDRATION PF DROPS   N  
propylene glycol/peg 400/PF SYSTANE ULTRA PF DROPS   N  
propylene glycol/PF SYSTANE COMPLETE PF DROPERETTE   N  
propylene glycol/PF SYSTANE COMPLETE PF DROPS   N  
propylene glycol/PF SYSTANE PRO PF DROPS   N  
revakinagene taroretcel-lwey ENCELTO IMPLANT   N  
riboflavin 5-phos/20 % dextran PHOTREXA CROSS-LINKING CMB DPVDP   N  
riboflavin 5-phos/20 % dextran PHOTREXA VISCOUS DROPS VISC   N  
riboflavin 5-phosphate sod(B2) PHOTREXA DROPS   N  
riboflavin 5-phosphate sod(B2) EPIOXA KIT   N  
sod borate/boric ac/water/NaCl EYE WASH IRRIG SOLN   N  
sodium chloride SODIUM CHLORIDE DROPS   N  
sodium chloride MURO-128 DROPS   N  
sodium chloride MURO-128 OINT. (G)   N  
sodium chloride SODIUM CHLORIDE OINT. (G)   N  
sodium chloride LENS PLUS SPRAY   N  
tetracaine HCl TETRACAINE HCL DROPS   N  
tetracaine HCl/PF TETRACAINE HCL DROPS   N  
triamcinolone acetonide/PF XIPERE VIAL   N  
trifluridine TRIFLURIDINE DROPS   N  
tropicamide TROPICAMIDE DROPS   N  
tropicamide MYDRIACYL DROPS   N  
tyloxapol ENUCLENE DROPS   N  
verteporfin VISUDYNE VIAL   N  
voretigene neparvovec-rzyl LUXTURNA VIAL Pharmacy PA Y Mar 22, 2018
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