- Quantity Limit: 204 strips per 30 day(s).
- May be covered under Medical Benefit.
- Step Therapy: Acute Migraine:
ST Multiple Generics
- Prior Authorization: Chemo-induced Nausea and Vomiting (CINV):
Duration: 1 year(s)
- Prior Authorization: Hepatitis B Treatment:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 3
Duration: 48 week(s)
Reauthorization Required: Yes
- Quantity Limit: 180 day supply per 365 day(s).
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