- Prior Authorization: Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Step Therapy: ST Generic and Brand
- Age Requirement: >= 18
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests;Medical Tests
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