- Step Therapy: Ophthalmic: Dry Eye:
Step Applies
- Quantity Limit: Maximum quantity 60 vials per prescription.
- Ophthalmic: Dry Eye:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Ophthalmologist;Optometrist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Prior Authorization: Ophthalmic: Dry Eye:
PA Applies
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