Ophthamic Allergy Products

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Ophthamic Allergy Products

Drugs

Quantity Limits

Elestat (Epinastine HCL) 0.05% Ophthalmic Drops 

5 mls per 30 Days

Emadine (Emedastine Difumarate) 0.05% Ophthalmic Drops 

5 mls per 30 Days

Optivar (Azelastine HCL) 0.05% Ophthalmic Drops 

6 mls per 30 Days

Pataday (Olopatadine HCL) 0.2% Ophthalmic Drops

2.5 mls per 30 Days

Patanol (Olopatadine HCL) 0.1% Ophthalmic Drops

5 mls per 30 Days

Zaditor (Ketotifen Famarate) 0.025% Ophthalmic Drops 

5 mls per 30 Days