Ophthamic Allergy Products

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Ophthamic Allergy Products
Drugs	Quantity Limits
Elestat (Epinastine HCL) 0.05% Ophthalmic Drops	5 mls per 30 Days
Emadine (Emedastine Difumarate) 0.05% Ophthalmic Drops	5 mls per 30 Days
Optivar (Azelastine HCL) 0.05% Ophthalmic Drops	6 mls per 30 Days
Pataday (Olopatadine HCL) 0.2% Ophthalmic Drops	2.5 mls per 30 Days
Patanol (Olopatadine HCL) 0.1% Ophthalmic Drops	5 mls per 30 Days
Zaditor (Ketotifen Famarate) 0.025% Ophthalmic Drops	5 mls per 30 Days

Last Modified on Nov 10, 2020

Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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