- Prior Authorization Required
- Step Therapy Applies
- Quantity Limit: 8 devices (4 kits) per
month
- Major Depressive Disorder:
Duration: 3 Month(s)
Specialist Required: Yes
Medical Test Required: No
Specialist Type(s): 1 of Psychiatrist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Documented Diagnosis: Yes
|