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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

The Oklahoma Health Care Authority collects the personally identifiable data submitted and received in regard to applications for services, renewals, appeals, provision of health care and processing of claims. This data is treated as confidential and is stored securely in accordance with applicable law and regulations. OHCA may share this personally identifiable data with its authorized business associates, government agencies with jurisdiction over the OHCA, or as otherwise required or permitted by applicable law.