UnitedHealthcare - 2014 to Present
Xiidra (lifitegrast)
Drugs for the Eye : Anti-Infective/Anti-Inflammatories
  • Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 1
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Severe Aplastic Anemia:
    Age Requirement: >= 2
    Duration: 6 Month(s)

  • Quantity Limit: 30 EA per 1 fill(s).
  • Quantity Limit: limit maximum 3 EA PER 1 day(s)