- Prior Authorization: Duchenne Muscular Dystrophy (DMD):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 7
Duration: 6 Month(s)
Reauthorization Required: Yes
- ST_APPLIES
- Quantity Limit: 100 grams per 30 day(s).
- Prior Authorization: Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Diabetic Medical Supplies:
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Prior Authorization: Diabetic Medical Supplies:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
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