Limited Coverage Drugs - Dorzolamide-timolol preservative free

Generic Name / Strength / Form

dorzolamide / timolol combination preservative-free ophthalmic

Special Authority Criteria

Approval Period

Diagnosis of ocular hypertension and open-angle glaucoma in patients with a demonstrated allergy to a specified preservative* Indefinite

Practitioner Exemptions

  • No practitioner exceptions

Special Notes

  • *Details of preservative and allergic response to be provided

Special Authority Request Form(s)