Ophthalmic Medications for Allergies

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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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00023429105 LASTACAFT ONCE DAILY RELIEF alcaftadine DROPS 0.25 % N Y N  
00023429110 LASTACAFT ONCE DAILY RELIEF alcaftadine DROPS 0.25 % N Y N  
47335093890 AZELASTINE HCL azelastine HCl DROPS 0.05 % Y N  
60505057804 AZELASTINE HCL azelastine HCl DROPS 0.05 % Y N  
61314030802 AZELASTINE HCL azelastine HCl DROPS 0.05 % Y N  
62332050606 AZELASTINE HCL azelastine HCl DROPS 0.05 % Y N  
70069009101 AZELASTINE HCL azelastine HCl DROPS 0.05 % Y N  
72266014101 AZELASTINE HCL azelastine HCl DROPS 0.05 % Y N  
00378705535 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
00378705567 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
24208063005 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
24208063010 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
60505611101 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
60505611102 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
62332059805 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
62332059810 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
70069071101 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
70069071201 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
82260063005 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
82260063010 BEPOTASTINE BESILATE bepotastine besilate DROPS 1.5 % Y N  
24208062901 BEPREVE bepotastine besilate DROPS 1.5 % Y N  
24208062902 BEPREVE bepotastine besilate DROPS 1.5 % Y N  
24208053708 LUMIFY brimonidine tartrate DROPS 0.025 % Y N  
24208053725 LUMIFY brimonidine tartrate DROPS 0.025 % Y N  
24208053775 LUMIFY brimonidine tartrate DROPS 0.025 % Y N  
24208053820 LUMIFY brimonidine tartrate/PF DROPERETTE 0.025 % Y N  
71776002430 ZERVIATE cetirizine HCl DROPERETTE 0.24 % Y N  
82667001524 ZERVIATE cetirizine HCl DROPERETTE 0.24 % Y N  
61314023710 CROMOLYN SODIUM cromolyn sodium DROPS 4 % Y N  
60505058401 EPINASTINE HCL epinastine HCl DROPS 0.05 % Y N  
70069000801 EPINASTINE HCL epinastine HCl DROPS 0.05 % Y N  
24208060110 ALAWAY ketotifen fumarate DROPS 0.025 % (0.035 %) Y N  
24208060190 ALAWAY ketotifen fumarate DROPS 0.025 % (0.035 %) Y N  
24208060105 CHILDREN'S ALAWAY ketotifen fumarate DROPS 0.025 % (0.035 %) Y N  
00536125240 EYE ITCH RELIEF ketotifen fumarate DROPS 0.025 % (0.035 %) Y N  
70000052201 EYE ITCH RELIEF ketotifen fumarate DROPS 0.025 % (0.035 %) Y N  
72485061710 KETOTIFEN FUMARATE ketotifen fumarate DROPS 0.025 % (0.035 %) Y N  
76385010617 KETOTIFEN FUMARATE ketotifen fumarate DROPS 0.025 % (0.035 %) Y N  
00065401105 ZADITOR ketotifen fumarate DROPS 0.025 % (0.035 %) Y N  
00065401106 ZADITOR ketotifen fumarate DROPS 0.025 % (0.035 %) Y N  
46122060605 REDNESS RELIEF naphazoline HCl/glycerin DROPS 0.012 %-0.25 % Y N  
70000001001 REDNESS RELIEF naphazoline HCl/glycerin DROPS 0.012 %-0.25 % Y N  
70000001002 REDNESS RELIEF naphazoline HCl/glycerin DROPS 0.012 %-0.25 % Y N  
70677116101 REDNESS RELIEF naphazoline HCl/glycerin DROPS 0.012 %-0.25 % Y N  
46122060305 MAX REDNESS RELIEF naphazoline HCl/glycerin DROPS 0.03 %-0.5 % Y N  
00074659201 CLEAR EYES ACR naphazoline HCl/zinc sulfate DROPS 0.012 % Y N  
00074659210 CLEAR EYES ACR naphazoline HCl/zinc sulfate DROPS 0.012 % Y N  
70000005401 EYE ALLERGY ITCH-REDNESS RLF olopatadine HCl DROPS 0.1 % Y N  
70677115601 EYE ALLERGY ITCH-REDNESS RLF olopatadine HCl DROPS 0.1 % Y N  
70677128001 EYE ALLERGY ITCH-REDNESS RLF olopatadine HCl DROPS 0.1 % Y N  
00536130840 OLOPATADINE HCL olopatadine HCl DROPS 0.1 % Y N  
00536144540 OLOPATADINE HCL olopatadine HCl DROPS 0.1 % Y N  
16571088205 OLOPATADINE HCL olopatadine HCl DROPS 0.1 % Y N  
43598076507 OLOPATADINE HCL olopatadine HCl DROPS 0.1 % Y N  
46122067264 OLOPATADINE HCL olopatadine HCl DROPS 0.1 % Y N  
70000071701 OLOPATADINE HCL olopatadine HCl DROPS 0.1 % Y N  
70069000701 OLOPATADINE HCL olopatadine HCl DROPS 0.1 % Y N  
70069001701 OLOPATADINE HCL olopatadine HCl DROPS 0.1 % Y N  
70512052005 OLOPATADINE HCL olopatadine HCl DROPS 0.1 % Y N  
00065427401 PATADAY TWICE DAILY RELIEF olopatadine HCl DROPS 0.1 % Y N  
24208061701 ADVANCED EYE RELIEF olopatadine HCl DROPS 0.2 % Y N  
70000005301 EYE ALLERGY ITCH RELIEF olopatadine HCl DROPS 0.2 % Y N  
70677115501 EYE ALLERGY ITCH RELIEF olopatadine HCl DROPS 0.2 % Y N  
00536130723 OLOPATADINE HCL olopatadine HCl DROPS 0.2 % Y N  
16571086125 OLOPATADINE HCL olopatadine HCl DROPS 0.2 % Y N  
43598076402 OLOPATADINE HCL olopatadine HCl DROPS 0.2 % Y N  
46122067127 OLOPATADINE HCL olopatadine HCl DROPS 0.2 % Y N  
68001053069 OLOPATADINE HCL olopatadine HCl DROPS 0.2 % Y N  
68001067492 OLOPATADINE HCL olopatadine HCl DROPS 0.2 % Y N  
70000071601 OLOPATADINE HCL olopatadine HCl DROPS 0.2 % Y N  
70069049101 OLOPATADINE HCL olopatadine HCl DROPS 0.2 % Y N  
70677012201 OLOPATADINE HCL olopatadine HCl DROPS 0.2 % Y N  
83324012025 OLOPATADINE HCL olopatadine HCl DROPS 0.2 % Y N  
00065815001 PATADAY ONCE DAILY RELIEF olopatadine HCl DROPS 0.2 % Y N  
00065815003 PATADAY ONCE DAILY RELIEF olopatadine HCl DROPS 0.2 % Y N  
00065081601 PATADAY ONCE DAILY RELIEF olopatadine HCl DROPS 0.7 % Y N  
00065081604 PATADAY ONCE DAILY RELIEF olopatadine HCl DROPS 0.7 % Y N  
24385007705 EYE DROPS tetrahydroz/dext 70/peg 400/pv DROPS 0.05 %-0.1 %-1 %-1 % Y N  
70000045601 EYE DROPS ADVANCED RELIEF tetrahydroz/dext 70/peg 400/pv DROPS 0.05 %-0.1 %-1 %-1 % Y N  
83324019114 EYE DROPS MOISTURIZING RELIEF tetrahydroz/dext 70/peg 400/pv DROPS 0.05 %-0.1 %-1 %-1 % Y N  
00536121794 EYE DROPS tetrahydrozoline HCl DROPS 0.05 % Y N  
24385007505 EYE DROPS tetrahydrozoline HCl DROPS 0.05 % Y N  
70000045401 EYE DROPS tetrahydrozoline HCl DROPS 0.05 % Y N  
70677115901 EYE DROPS tetrahydrozoline HCl DROPS 0.05 % Y N  
83324029615 EYE DROPS tetrahydrozoline HCl DROPS 0.05 % Y N  
83324034015 EYE DROPS tetrahydrozoline HCl DROPS 0.05 % Y N  
00074265205 MURINE PLUS tetrahydrozoline HCl DROPS 0.05 % Y N  
00074265226 MURINE PLUS tetrahydrozoline HCl DROPS 0.05 % Y N  
83324019014 EYE DROPS IRRITATION RELIEF tetrahydrozoline HCl/zinc sulf DROPS 0.05 %-0.25 % Y N  
46122060205 EYE DROPS SEASONAL RELIEF tetrahydrozoline HCl/zinc sulf DROPS 0.05 %-0.25 % Y N  
70677115801 EYE DROPS tetrahydrozoline/polyethyl gly DROPS 0.05 %-1 % Y N  
46122075829 MULTI-SYMPTOM RELIEF EYE tetrahydrozoline/zinc/peg 400 DROPS 0.05 %-0.25 %-1 % Y N  
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