Western Health Advantage - All plan years
Upneeq (oxymetazoline (PF))
Drugs for the Eye : Drugs for the Eye
  • PA_APPLIES
  • Prior Authorization: Adjunctive Rheumatoid Arthritis:
    Documented Diagnosis: Yes

    Infantile Spasm:
    Documented Diagnosis: Yes
    Age Requirement: < 2
    Duration: 3 Month(s)
    Reauthorization Required: Yes

    Multiple Sclerosis Exacerbation:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 3 week(s)

    Nephrotic Syndrome:
    Documented Diagnosis: Yes
    Age Requirement: > 2
    Duration: 3 Month(s)
    Reauthorization Required: Yes

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