- Quantity Limit: limit maximum 750 mL PER 30 day(s)
- Prior Authorization: Diabetic Retinopathy, Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO), Neovascular (Wet) Age-Related Macular Degeneration (AMD):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Myopic Choroidal Neovascularization (mCNV): Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 3 Month(s)
Reauthorization Required: Yes
|