- Step Therapy Applies
- Prior authorization required. Member should try alternative(s) before submitting a prior authorization. If approved, covered at appropriate tier under the member's pharmacy benefit.
- Quantity Limit: Maximum quantity of 31 per 31 Day(s). Maximum quantity 1 tablet per day.
- Prior Authorization: Prior authorization required. Member should try alternative(s) before submitting a prior authorization. If approved, covered at appropriate tier under the member's pharmacy benefit.
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