Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
dorzolamide / timolol combination preservative-free ophthalmic

Criteria Approval Period

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

 Indefinite

Practitioner Exemptions

  • None


Special Notes

  • *Details of preservative and allergic response to be provided

Online Forms (PDF)
Click on the link to complete a special authority request form.