- Step Therapy Applies
- Prior Authorization: Primary Axillary Hyperhidrosis:
Documented Diagnosis: Yes
Age Requirement: >= 9
Duration: 1 year(s)
- PA Required
- Primary Axillary Hyperhidrosis:
Age Requirement: >= 9
Duration: 1 year(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Policy Contains Verbiage for Botulinum Interchangeability: No
Documented Diagnosis: Yes
|