- Quantity Limit: 0.28 mL per day)
- Prior Authorization: PA Applies
- Quantity Limit: 1 capsule per 1 day(s).
- Assisted Reproductive Technology (ART):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
- Quantity Limit: 204 lancets per 30 day(s).
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