Otic Antibiotics
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 | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 42195055014 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPERETTE | 0.2 % | N | Y | |
| 64950038114 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPERETTE | 0.2 % | N | Y | |
| 69543045714 | CIPROFLOXACIN HCL | ciprofloxacin HCl | DROPERETTE | 0.2 % | N | Y | |
| 00781618667 | CIPROFLOXACIN-DEXAMETHASONE | ciprofloxacin HCl/dexameth | DROPS SUSP | 0.3 %-0.1 % | N | Y | |
| 16714062801 | CIPROFLOXACIN-DEXAMETHASONE | ciprofloxacin HCl/dexameth | DROPS SUSP | 0.3 %-0.1 % | N | Y | |
| 43598032675 | CIPROFLOXACIN-DEXAMETHASONE | ciprofloxacin HCl/dexameth | DROPS SUSP | 0.3 %-0.1 % | N | Y | |
| 53746083153 | CIPROFLOXACIN-DEXAMETHASONE | ciprofloxacin HCl/dexameth | DROPS SUSP | 0.3 %-0.1 % | N | Y | |
| 62756042790 | CIPROFLOXACIN-DEXAMETHASONE | ciprofloxacin HCl/dexameth | DROPS SUSP | 0.3 %-0.1 % | N | Y | |
| 72485062513 | CIPROFLOXACIN-DEXAMETHASONE | ciprofloxacin HCl/dexameth | DROPS SUSP | 0.3 %-0.1 % | N | Y | |
| 42195012814 | CIPROFLOXACIN HCL-FLUOCINOLONE | ciprofloxacin HCl/fluocinolone | VIAL | 0.3 %-0.025 % (0.25 mL) | N | Y | |
| 24338008001 | OTOVEL | ciprofloxacin HCl/fluocinolone | VIAL | 0.3 %-0.025 % (0.25 mL) | N | Y | |
| 00078085526 | CIPRO HC | ciprofloxacin/hydrocortisone | DROPS SUSP | 0.2 %-1 % | N | Y | |
| 66758008770 | CIPRO HC | ciprofloxacin/hydrocortisone | DROPS SUSP | 0.2 %-1 % | N | Y | |
| 63481052910 | CORTISPORIN-TC | neomyc/colist/hydrocort/thonzn | DROPS SUSP | 3.3 mg-3 mg-10 mg-0.5 mg/mL | Y | Y | |
| 61314064175 | NEOMYCIN-POLYMYXIN-HC | neomycin/polymyxin B/hydrocort | DROPS SUSP | 3.5 mg-10,000 unit-10 mg/mL | N | Y | |
| 24208063562 | NEOMYCIN-POLYMYXIN-HC | neomycin/polymyxin B/hydrocort | DROPS SUSP | 3.5 mg/mL-10,000 unit/mL-1 % | Y | Y | |
| 61314064511 | NEOMYCIN-POLYMYXIN-HC | neomycin/polymyxin B/hydrocort | DROPS SUSP | 3.5 mg/mL-10,000 unit/mL-1 % | Y | Y | |
| 64980044801 | NEOMYCIN-POLYMYXIN-HC | neomycin/polymyxin B/hydrocort | DROPS SUSP | 3.5 mg/mL-10,000 unit/mL-1 % | Y | Y | |
| 00884408610 | LAZERSPORIN-C | neomycin/polymyxin B/hydrocort | SOLUTION | 3.5 mg/mL-10,000 unit/mL-1 % | N | Y | |
| 24208063110 | NEOMYCIN-POLYMYXIN-HYDROCORT | neomycin/polymyxin B/hydrocort | SOLUTION | 3.5 mg/mL-10,000 unit/mL-1 % | N | Y | |
| 00904743405 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 00904743410 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 24208041005 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 24208041010 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 24208043405 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 24208043410 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 60505036301 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 60505036302 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 60505056000 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 60505056001 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 64980043201 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 64980043205 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 64980051501 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 64980051505 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 65145014101 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 65145014201 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 65145014301 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 65145014401 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 69238161503 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 69238161606 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 69315032005 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 69315032010 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 69315032705 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 69315032710 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 70069041101 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 70069068601 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 70069068701 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 70512079305 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 70512079310 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 70756060730 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 70756060915 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 70756061030 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 70756065030 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 72485061310 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 72485061311 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 72603018601 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 72603018602 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 72603019201 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y | |
| 72603019202 | OFLOXACIN | ofloxacin | DROPS | 0.3 % | Y | Y |