Limited Coverage Drugs - Dorzolamide-timolol preservative free


Generic Name

 

dorzolamide / timolol combination preservative-free ophthalmic


Strength

2 %-0.5 % 

Form

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.
 

Indefinite

Practitioner Exemptions

  • No practitioner exceptions.

Special Notes

  • Details of preservative and allergic response to be provided.

Special Authority Request Form(s)