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Ophthamic Preparations

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

Ophthamic Preparations
Drugs	Quantity Limits
Alamast (Pemirolast Potassium) 0.1% Ophthalmic Drops	10 mls per 30 Days
Alocril (Nedocromil Sodium) 2% Ophthalmic Drops	5 mls per 30 Days
Alomide (Lodoxamide Tromethamine) 0.1% Ophthalmic Drops	10 mls per 30 Days
Alrex (Loteprednol Etabonate) 0.2% Ophthalmic Drops	10mls per 30 Days
Crolom (Cromolyn Sodium) 4% Ophthalmic Drops	10 mls per 30 Days

Last Modified on Nov 10, 2020