- Step Therapy: ST Multiple Generics
- Prior Authorization: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 3 Month(s)
Reauthorization Required: Yes
- Age Requirement: >= 18
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Ophthalmologist
Reauthorization Required: Yes
Duration of Reauthorization: = 3 month(s)
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