- Prior Authorization: PA Applies
- Diabetic Retinopathy, Macular Edema Following Retinal Vein Occlusion (RVO), Neovascular (Wet) Age-Related Macular Degeneration (AMD):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Ophthalmologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Macular Edema:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Ophthalmologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
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