- Prior Authorization: Intestinal worm (helminthes) Infection:
Documented Diagnosis: Yes
Duration: 1 Month(s)
- Step Therapy: Intestinal worm (helminthes) Infection:
ST Single Brand
- Quantity Limit: limit maximum 124 EA PER 30 day(s)
- Intestinal worm (helminthes) Infection:
Duration: 1 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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