- PA_APPLIES
- Prior Authorization: Hemophilia A (Factor VIII):
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Hemophilia A or B with Inhibitor:
PA Applies
- Derm: Acne Vulgaris:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Limited to non-cosmetic use: No
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
- Step Therapy: Graft Versus Host Disease (GVHD):
ST Single Generic
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