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Ophthalmic Agents (Allergy)
Name AETNA BCBSMA BMCHP FCHP HPHC HNE NHP NTWK MAHLTH THP
DICLOFENAC [Voltaren] FE X* PA X NC X PA X
EMEDAsTINE DIFUMARATE
[Emadine]
FE DL PA X PA X
EPINAsTINE HCL [Elestat] FE NC DL PA X PA X
FLURBIPROFEN X* X* X X X X X X X X
KETOTIFEN NC NC X X X X NC NC
KETOTIFEN solution (OTC) NC NC X NC NC X X X
KETOTIFEN [Alaway OTC] NC NC X NC NC X X X X
KETOTIFEN [zaditor OTC] NC NC PA NC NC X X X
LODOXAMIDE TROMETHAMINE
[Alomide]
FE DL PA X X PA PA X
LOTEPREDNOL [Alrex] X* NC DL X X X X X PA X
NAPHAzOLINE (Rx) X* X* X X X X X X X
NAPHAzOLINE/PHENIRAMINE (OTC) NC NC X NC NC X X X
NAPHAzOLINE/PHENIRAMINE
[Naphcon-A] (OTC)
NC NC PA NC NC NC X X
NAPHAzOLINE/PHENIRAMINE
[Opcon-A] (OTC)
NC NC PA NC NC NC X X
NAPHAzOLINE/PHENIRAMINE
[Visine-A] (OTC)
NC NC X NC NC NC X X
NEDOCROMIL sODIUM [Alocril] FE NC DL PA X PA PA X
OLOPATADINE 0 .1% [Patanol] FE DL PA X X PA PA X
OLOPATADINE 0 .2% [Pataday] X* NC DL PA X X PA NC
PEMIROLAsT [Alamast] FE NC DL PA X X PA PA X
PHENyLEPHRINE (OTC) FE NC X NC NC X
RIMEXOLONE [Vexol] FE X* X X X X X X
Ophthalmic Agents (Antibiotic)
AzITHROMyCIN [Azasite] X* NC PA X DL PA DL
BACITRACIN/NEOMyCIN/
POLyMyXIN B
X* X* X X X X X X X X
BACITRACIN ointment X* X* X X X X X X X X
BACITRACIN/POLyMyXIN B X* X* X X X X X X X X
BACITRACIN/POLyMyXIN B
[Polysporin]
X X X X X NC X
40