Antibiotics, Ophthalmic
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 82584030703 | AZASITE | azithromycin | DROPS | 1 % | N | Y | N | |
| 00363007564 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 00713028031 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 00927009430 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 11673007358 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 11917005749 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 11917018788 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 12810006003 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 16784011631 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 37097006003 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 41280020078 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 43072000638 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 49158012206 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 49158012208 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 49999014215 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 50090081500 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 51672200503 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 52959021706 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 52959133703 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 52959133706 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 52959137603 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 52959137605 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 54868326900 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 59390002617 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 59779053664 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 66267098830 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 66267098915 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 67777011620 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 67777011621 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 67777011630 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 67777011631 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 67777021901 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 71205005701 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 87701095027 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 94441020078 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | N | N | |
| 00536125628 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | Y | N | |
| 00574402235 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | N | Y | N | |
| 45802006001 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | Y | N | |
| 45802006003 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | Y | N | |
| 45802006004 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | Y | N | |
| 45802006005 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | Y | N | |
| 45802006010 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | Y | N | |
| 45802006023 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | Y | N | |
| 45802006044 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | Y | N | |
| 45861007303 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | Y | N | |
| 68001047746 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | Y | N | |
| 68001047747 | BACITRACIN | bacitracin | OINT. (G) | 500 unit/gram | Y | Y | N | |
| 24208055555 | BACITRACIN-POLYMYXIN | bacitracin/polymyxin B sulfate | OINT. (G) | 500 unit-10,000 unit/gram | Y | Y | N | |
| 00574402135 | POLYCIN | bacitracin/polymyxin B sulfate | OINT. (G) | 500 unit-10,000 unit/gram | Y | Y | N | |
| 24208044605 | BESIVANCE | besifloxacin HCl | DROPS SUSP | 0.6 % | N | Y | N | |
| 60793030701 | CHLORAMPHENICOL | chloramphenicol | OINT. (G) | 1 % | N | Y | N | |
| 61314065605 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPS | 0.3 % | Y | Y | N | |
| 61314065610 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPS | 0.3 % | Y | Y | N | |
| 61314065625 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPS | 0.3 % | Y | Y | N | |
| 69315030802 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPS | 0.3 % | Y | Y | N | |
| 69315030805 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPS | 0.3 % | Y | Y | N | |
| 69315030810 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPS | 0.3 % | Y | Y | N | |
| 72888010221 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPS | 0.3 % | Y | Y | N | |
| 72888010222 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPS | 0.3 % | Y | Y | N | |
| 72888010223 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPS | 0.3 % | Y | Y | N | |
| 66758007138 | CILOXAN | ciprofloxacin HCl | OINT. (G) | 0.3 % | Y | Y | N | |
| 00574402411 | ERYTHROMYCIN | erythromycin base | OINT. (G) | 5 mg/gram (0.5 %) | Y | Y | N | |
| 00574402435 | ERYTHROMYCIN | erythromycin base | OINT. (G) | 5 mg/gram (0.5 %) | Y | Y | N | |
| 00574402439 | ERYTHROMYCIN | erythromycin base | OINT. (G) | 5 mg/gram (0.5 %) | Y | Y | N | |
| 00574402450 | ERYTHROMYCIN | erythromycin base | OINT. (G) | 5 mg/gram (0.5 %) | Y | Y | N | |
| 24208091019 | ERYTHROMYCIN | erythromycin base | OINT. (G) | 5 mg/gram (0.5 %) | Y | Y | N | |
| 24208091055 | ERYTHROMYCIN | erythromycin base | OINT. (G) | 5 mg/gram (0.5 %) | Y | Y | N | |
| 72485067031 | ERYTHROMYCIN | erythromycin base | OINT. (G) | 5 mg/gram (0.5 %) | Y | Y | N | |
| 72485067035 | ERYTHROMYCIN | erythromycin base | OINT. (G) | 5 mg/gram (0.5 %) | Y | Y | N | |
| 61314067225 | GATIFLOXACIN | gatifloxacin | DROPS | 0.5 % | N | Y | N | |
| 69315033102 | GATIFLOXACIN | gatifloxacin | DROPS | 0.5 % | N | Y | N | |
| 11980011705 | GENOPTIC | gentamicin sulfate | DROPS | 0.3 % | Y | Y | N | |
| 24208058060 | GENTAMICIN SULFATE | gentamicin sulfate | DROPS | 0.3 % | Y | Y | N | |
| 61314063305 | GENTAMICIN SULFATE | gentamicin sulfate | DROPS | 0.3 % | Y | Y | N | |
| 72888014222 | LEVOFLOXACIN | levofloxacin | DROPS | 0.5 % | N | Y | N | |
| 00781713593 | MOXIFLOXACIN | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 00832141003 | MOXIFLOXACIN | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 16714064301 | MOXIFLOXACIN | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 60505058204 | MOXIFLOXACIN | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 62332050503 | MOXIFLOXACIN | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 65862084003 | MOXIFLOXACIN | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 68180042201 | MOXIFLOXACIN | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 70069008101 | MOXIFLOXACIN | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 70756063825 | MOXIFLOXACIN | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 72266015801 | MOXIFLOXACIN | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 00078093926 | VIGAMOX | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 82667070003 | VIGAMOX | moxifloxacin HCl | DROPS | 0.5 % | Y | Y | N | |
| 71776000515 | NATACYN | natamycin | DROPS SUSP | 5 % | Y | Y | N | |
| 82667001205 | NATACYN | natamycin | DROPS SUSP | 5 % | Y | Y | N | |
| 00574425035 | NEO-POLYCIN | neomycin/bacitracin/polymyxinB | OINT. (G) | 3.5 mg-400 unit-10,000 unit/gram | N | Y | N | |
| 16571075453 | NEOMYCIN-BACITRACIN-POLYMYXIN | neomycin/bacitracin/polymyxinB | OINT. (G) | 3.5 mg-400 unit-10,000 unit/gram | N | Y | N | |
| 24208078055 | NEOMYCIN-BACITRACIN-POLYMYXIN | neomycin/bacitracin/polymyxinB | OINT. (G) | 3.5 mg-400 unit-10,000 unit/gram | N | Y | N | |
| 60793026610 | NEOMYCIN/POLYMYXIN/GRAMICIDIN | neomycin/polymyxn B/gramicidin | DROPS | Y | Y | N | ||
| 00603722539 | NEOPTIC | neomycin/polymyxn B/gramicidin | DROPS | Y | Y | N | ||
| 24208079062 | NEOMYCIN-POLYMYXIN-GRAMICIDIN | neomycin/polymyxn B/gramicidin | DROPS | 1.75 mg-10,000 unit-0.025 mg/mL | Y | Y | N | |
| 11980077905 | OCUFLOX | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 00904743405 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 00904743410 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 24208041005 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 24208041010 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 24208043405 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 24208043410 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 60505036301 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 60505036302 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 60505056000 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 60505056001 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 64980043201 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 64980043205 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 64980051501 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 64980051505 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 65145014101 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 65145014201 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 65145014301 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 65145014401 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 69238161503 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 69238161606 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 69315032005 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 69315032010 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 69315032705 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 69315032710 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 70069041101 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 70069068601 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 70069068701 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 70512079305 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 70512079310 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 70756060730 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 70756060915 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 70756061030 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 70756065030 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 72485061310 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 72485061311 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 72603018601 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 72603018602 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 72603019201 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 72603019202 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | N | |
| 00049080108 | TERRAMYCIN WITH POLYMYXIN | oxytetracycline/polymyxin B | OINT. (G) | 5 mg-10,000 unit/gram | N | Y | N | |
| 24208031510 | POLYMYXIN B SUL-TRIMETHOPRIM | polymyxin B sulf/trimethoprim | DROPS | 10,000 unit-1 mg/mL | Y | Y | N | |
| 61314062810 | POLYMYXIN B SUL-TRIMETHOPRIM | polymyxin B sulf/trimethoprim | DROPS | 10,000 unit-1 mg/mL | Y | Y | N | |
| 70069031101 | POLYMYXIN B SUL-TRIMETHOPRIM | polymyxin B sulf/trimethoprim | DROPS | 10,000 unit-1 mg/mL | Y | Y | N | |
| 00603728041 | SULFACETAMIDE SODIUM | sulfacetamide sodium | DROPS | 10 % | Y | Y | N | |
| 24208067004 | SULFACETAMIDE SODIUM | sulfacetamide sodium | DROPS | 10 % | Y | Y | N | |
| 00998052205 | ISOPTO CETAMIDE | sulfacetamide sodium | DROPS | 15 % | Y | Y | N | |
| 00574419035 | SULFACETAMIDE SODIUM | sulfacetamide sodium | OINT. (G) | 10 % | N | Y | N | |
| 24208029005 | TOBRAMYCIN | tobramycin | DROPS | 0.3 % | Y | Y | N | |
| 61314064305 | TOBRAMYCIN | tobramycin | DROPS | 0.3 % | Y | Y | N | |
| 62332051805 | TOBRAMYCIN | tobramycin | DROPS | 0.3 % | Y | Y | N | |
| 70069013101 | TOBRAMYCIN | tobramycin | DROPS | 0.3 % | Y | Y | N | |
| 00078081301 | TOBREX | tobramycin | OINT. (G) | 0.3 % | Y | Y | N |