Special Authority Criteria




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Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form

dorzolamide/timolol 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.

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Last Revised: June 18, 2007