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)
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