Ophthamic Preparations

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

Ophthamic Preparations

Drugs

Quantity Limits

Alamast (Pemirolast Potassium) 0.1% Ophthalmic Drops 

10 mls per 30 Days

Alocril (Nedocromil Sodium) 2% Ophthalmic Drops 

5 mls per 30 Days

Alomide (Lodoxamide Tromethamine) 0.1% Ophthalmic Drops 

10 mls per 30 Days

Alrex (Loteprednol Etabonate) 0.2% Ophthalmic Drops 

10mls per 30 Days

Crolom (Cromolyn Sodium) 4% Ophthalmic Drops 

10 mls per 30 Days