| Anthem Blue Cross (HMO, PPO, EPO) |
| Eysuvis (loteprednol etabonate) |
| Drugs for the Eye : Anti-Infective/Anti-Inflammatories |
- Prior Authorization: Ophthalmic: Dry Eye:
PA Applies
- Quantity Limit: limit maximum 20 mL PER 30 day(s)
- Ophthalmic: Dry Eye:
Age Requirement: >= 18
Duration: 1 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Supporting Documentation Requirements: Medical Tests
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