- Step Therapy Applies
- Maximum $200 copayment per State Law
- Prior Authorization: Sickle Cell Disease:
Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 1 plan year
Reauthorization Required: Yes
- Sickle Cell Disease:
Age Requirement: >= 2
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
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