- Step Therapy: Ophthalmic: Dry Eye:
Step Applies
- Prior Authorization: Ophthalmic: Dry Eye:
PA Applies
- Ophthalmic: Dry Eye:
Age Requirement: >= 17
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Supporting Documentation Requirements: Chart Notes
|