Limited Coverage Drugs - Dorzolamide-timolol preservative free

Generic Name


dorzolamide / timolol combination preservative-free ophthalmic


2 %-0.5 % 


Sterile Ophthalmic Solution

Special Authority Criteria

Approval Period

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

See special notes below.


Practitioner Exemptions

  • No practitioner exceptions.

Special Notes

  • Details of preservative and allergic response to be provided.

Special Authority Request Form(s)