Anti-Inflammatory Drugs, Ophthalmic

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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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
60505100602 BROMFENAC SODIUM bromfenac sodium DROPS 0.07 % N Y N  
62332058303 BROMFENAC SODIUM bromfenac sodium DROPS 0.07 % N Y N  
68180043302 BROMFENAC SODIUM bromfenac sodium DROPS 0.07 % N Y N  
75907009303 BROMFENAC SODIUM bromfenac sodium DROPS 0.07 % N Y N  
82260060203 BROMFENAC SODIUM bromfenac sodium DROPS 0.07 % N Y N  
24208060203 PROLENSA bromfenac sodium DROPS 0.07 % N Y N  
49708075541 BROMFENAC SODIUM bromfenac sodium DROPS 0.075 % N Y N  
68180043401 BROMFENAC SODIUM bromfenac sodium DROPS 0.075 % N Y N  
49708075441 BROMSITE bromfenac sodium DROPS 0.075 % N Y N  
62332050817 BROMFENAC SODIUM bromfenac sodium DROPS 0.09 % N Y N  
65862078917 BROMFENAC SODIUM bromfenac sodium DROPS 0.09 % N Y N  
68180043601 BROMFENAC SODIUM bromfenac sodium DROPS 0.09 % N Y N  
72266014201 BROMFENAC SODIUM bromfenac sodium DROPS 0.09 % N Y N  
72485064971 BROMFENAC SODIUM bromfenac sodium DROPS 0.09 % N Y N  
00078092525 MAXIDEX dexamethasone DROPS SUSP 0.1 % Y Y N  
82667060005 MAXIDEX dexamethasone DROPS SUSP 0.1 % Y Y N  
70382020401 DEXTENZA dexamethasone INSERT 0.4 mg Y N  
70382020410 DEXTENZA dexamethasone INSERT 0.4 mg Y N  
70382020488 DEXTENZA dexamethasone INSERT 0.4 mg Y N  
24208072002 DEXAMETHASONE SODIUM PHOSPHATE dexamethasone sodium phosphate DROPS 0.1 % Y Y N  
24208045705 DICLOFENAC SODIUM diclofenac sodium DROPS 0.1 % Y Y N  
61314001405 DICLOFENAC SODIUM diclofenac sodium DROPS 0.1 % Y Y N  
61314001425 DICLOFENAC SODIUM diclofenac sodium DROPS 0.1 % Y Y N  
72888015021 DICLOFENAC SODIUM diclofenac sodium DROPS 0.1 % Y Y N  
72888015022 DICLOFENAC SODIUM diclofenac sodium DROPS 0.1 % Y Y N  
45861006205 DICLOFENAC SODIUM diclofenac sodium DROPS 1.5 % N Y N  
51672135802 DICLOFENAC SODIUM diclofenac sodium DROPS 1.5 % N Y N  
59088037210 DICLOFENAC SODIUM diclofenac sodium DROPS 1.5 % N Y N  
59088043510 DICLOFENAC SODIUM diclofenac sodium DROPS 1.5 % N Y N  
65162091174 DICLOFENAC SODIUM diclofenac sodium DROPS 1.5 % N Y N  
68180053801 DICLOFENAC SODIUM diclofenac sodium DROPS 1.5 % N Y N  
70512003805 DICLOFENAC SODIUM diclofenac sodium DROPS 1.5 % N Y N  
70512081005 DICLOFENAC SODIUM diclofenac sodium DROPS 1.5 % N Y N  
71085000205 DICLOFENAC SODIUM diclofenac sodium DROPS 1.5 % N Y N  
00378751835 DIFLUPREDNATE difluprednate DROPS 0.05 % N Y N  
00781600078 DIFLUPREDNATE difluprednate DROPS 0.05 % N Y N  
00832605405 DIFLUPREDNATE difluprednate DROPS 0.05 % N Y N  
43598058811 DIFLUPREDNATE difluprednate DROPS 0.05 % N Y N  
65145016101 DIFLUPREDNATE difluprednate DROPS 0.05 % N Y N  
69097034135 DIFLUPREDNATE difluprednate DROPS 0.05 % N Y N  
69238138003 DIFLUPREDNATE difluprednate DROPS 0.05 % N Y N  
69315032905 DIFLUPREDNATE difluprednate DROPS 0.05 % N Y N  
76282070850 DIFLUPREDNATE difluprednate DROPS 0.05 % N Y N  
66758008675 DUREZOL difluprednate DROPS 0.05 % N Y N  
60219158503 FLUOROMETHOLONE fluorometholone DROPS SUSP 0.1 % Y Y N  
60219158606 FLUOROMETHOLONE fluorometholone DROPS SUSP 0.1 % Y Y N  
60758088005 FLUOROMETHOLONE fluorometholone DROPS SUSP 0.1 % Y Y N  
60758088010 FLUOROMETHOLONE fluorometholone DROPS SUSP 0.1 % Y Y N  
11980021105 FML fluorometholone DROPS SUSP 0.1 % Y Y N  
11980021110 FML fluorometholone DROPS SUSP 0.1 % Y Y N  
11980022805 FML FORTE fluorometholone DROPS SUSP 0.25 % N Y N  
11980022810 FML FORTE fluorometholone DROPS SUSP 0.25 % N Y N  
71776010005 FLAREX fluorometholone acetate DROPS SUSP 0.1 % N Y N  
69292072225 FLURBIPROFEN SODIUM flurbiprofen sodium DROPS 0.03 % Y Y N  
00023927705 ACULAR LS ketorolac tromethamine DROPS 0.4 % Y Y N  
60758077305 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.4 % Y Y N  
00023218105 ACULAR ketorolac tromethamine DROPS 0.5 % Y Y N  
00023218110 ACULAR ketorolac tromethamine DROPS 0.5 % Y Y N  
42571013725 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
42571013726 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
47335022090 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
60505100301 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
60505100302 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
61314012605 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
61314012610 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
65145013901 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
65145014001 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
69315032205 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
69315032210 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
70512079005 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
70512079010 KETOROLAC TROMETHAMINE ketorolac tromethamine DROPS 0.5 % Y Y N  
00023350731 ACUVAIL ketorolac tromethamine/PF DROPERETTE 0.45 % N Y N  
24208050707 LOTEMAX SM loteprednol etabonate DROPS GEL 0.38 % N Y N  
24208050307 LOTEMAX loteprednol etabonate DROPS GEL 0.5 % N Y N  
24208050801 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS GEL 0.5 % N Y N  
72485063005 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS GEL 0.5 % N Y N  
82260050801 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS GEL 0.5 % N Y N  
24208035305 ALREX loteprednol etabonate DROPS SUSP 0.2 % N Y N  
24208035310 ALREX loteprednol etabonate DROPS SUSP 0.2 % N Y N  
60219136603 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.2 % N Y N  
72485065305 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.2 % N Y N  
72485065310 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.2 % N Y N  
82260036105 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.2 % N Y N  
24208029905 LOTEMAX loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
24208029910 LOTEMAX loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
24208029915 LOTEMAX loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
60219136201 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
62756023255 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
62756023256 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
62756023290 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
70748030001 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
70748030002 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
72485066505 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
72603032401 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
72603032402 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
72603032403 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
82260029905 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
82260029910 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
82260029915 LOTEPREDNOL ETABONATE loteprednol etabonate DROPS SUSP 0.5 % Y Y N  
71571012128 INVELTYS loteprednol etabonate DROPS SUSP 1 % N Y N  
24208044335 LOTEMAX loteprednol etabonate OINT. (G) 0.5 % N Y N  
00078077803 NEVANAC nepafenac DROPS SUSP 0.1 % N Y N  
82667050003 NEVANAC nepafenac DROPS SUSP 0.1 % N Y N  
00078074303 ILEVRO nepafenac DROPS SUSP 0.3 % N Y N  
82667040003 ILEVRO nepafenac DROPS SUSP 0.3 % N Y N  
11980017405 PRED MILD prednisolone acetate DROPS SUSP 0.12 % N Y N  
11980017410 PRED MILD prednisolone acetate DROPS SUSP 0.12 % N Y N  
11980018005 PRED FORTE prednisolone acetate DROPS SUSP 1 % Y Y N  
11980018010 PRED FORTE prednisolone acetate DROPS SUSP 1 % Y Y N  
11980018015 PRED FORTE prednisolone acetate DROPS SUSP 1 % Y Y N  
60758011905 PREDNISOLONE ACETATE prednisolone acetate DROPS SUSP 1 % Y Y N  
60758011910 PREDNISOLONE ACETATE prednisolone acetate DROPS SUSP 1 % Y Y N  
60758011915 PREDNISOLONE ACETATE prednisolone acetate DROPS SUSP 1 % Y Y N  
61314063705 PREDNISOLONE ACETATE prednisolone acetate DROPS SUSP 1 % Y Y N  
61314063710 PREDNISOLONE ACETATE prednisolone acetate DROPS SUSP 1 % Y Y N  
61314063715 PREDNISOLONE ACETATE prednisolone acetate DROPS SUSP 1 % Y Y N  
70748033202 PREDNISOLONE ACETATE prednisolone acetate DROPS SUSP 1 % Y Y N  
70748033203 PREDNISOLONE ACETATE prednisolone acetate DROPS SUSP 1 % Y Y N  
70748033204 PREDNISOLONE ACETATE prednisolone acetate DROPS SUSP 1 % Y Y N  
24208071510 PREDNISOLONE SODIUM PHOSPHATE prednisolone sodium phosphate DROPS 1 % N Y N  
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