- Prior Authorization: Ophthalmic: Dry Eye:
PA Applies
- Quantity Limit: limit maximum 2 EA PER 1 day(s) OR limit maximum 64 EA PER fill retail
- Step Therapy: Ophthalmic: Dry Eye:
Step Applies
- Ophthalmic: Dry Eye:
Age Requirement: >= 16
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Supporting Documentation Requirements: 1 of Chart Notes;Medical Tests
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