- Quantity Limit: limit maximum 3 EA PER 1 day(s)
- Step Therapy: Diabetic Peripheral Neuropathy:
ST Multiple Generics
- Diabetic Peripheral Neuropathy:
Age Requirement: >= 18
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
- Prior Authorization: Diabetic Peripheral Neuropathy:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
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