All *OPHTHALMIC AGENTS*

Acular LS Solution 0.4 % Ophthalmic
Acular LS Solution 0.4 % Ophthalmic

Ketorolac Tromethamine

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Acular Solution 0.5 % Ophthalmic
Acular Solution 0.5 % Ophthalmic

Ketorolac Tromethamine

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Acuvail Solution 0.45 % Ophthalmic
Acuvail Solution 0.45 % Ophthalmic

Ketorolac Tromethamine (PF)

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
AK-Fluor SOLUTION 10 % Intravenous
AK-Fluor SOLUTION 10 % Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
AK-Fluor SOLUTION 25 % Intravenous
AK-Fluor SOLUTION 25 % Intravenous

Tier: 3
PA Type: No Prior Authorization
ST: N
AK-Poly-Bac Ointment 500-10000 UNIT/GM Ophthalmic
AK-Poly-Bac Ointment 500-10000 UNIT/GM Ophthalmic

Tier: 1
PA Type: No Prior Authorization
ST: N
Akten GEL 3.5 % OPHTHALMIC
Akten GEL 3.5 % OPHTHALMIC

Lidocaine HCl

Tier: 3
PA Type: No Prior Authorization
ST: N
Akten GEL 3.5 % OPHTHALMIC
Akten GEL 3.5 % OPHTHALMIC

Lidocaine HCl

Tier: 3
PA Type: No Prior Authorization
ST: N
Alcaine Solution 0.5 % Ophthalmic
Alcaine Solution 0.5 % Ophthalmic

Proparacaine HCl

Tier: 3
PA Type: No Prior Authorization
ST: N
Alocril SOLUTION 2 % OPHTHALMIC
Alocril SOLUTION 2 % OPHTHALMIC

Nedocromil Sodium

Tier: 3
PA Type: No Prior Authorization
ST: N
Alomide SOLUTION 0.1 % OPHTHALMIC
Alomide SOLUTION 0.1 % OPHTHALMIC

Lodoxamide Tromethamine

Tier: 3
PA Type: No Prior Authorization
ST: N
Alphagan P Solution 0.1 % Ophthalmic
Alphagan P Solution 0.1 % Ophthalmic

Brimonidine Tartrate

Tier: 2
PA Type: No Prior Authorization
ST: N