- Step Therapy: Diabetes Type 2: GLP1 + Combo:
ST Single Generic
- Diabetes Type 2: GLP1 + Combo:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Supporting Documentation Requirements: Medication History
- Quantity Limit: 4 vials per pen-inj per 28 days
- Prior Authorization: Diabetes Type 2: GLP1 + Combo:
Documented Diagnosis: Yes
Duration: 12 Month(s)
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