- Diabetic Medical Supplies:
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
- Step Therapy: Long-chain fatty acid oxidation disorders (LC-FAOD):
ST Single Generic
- Quantity Limit: 3 bottles (21.96 grams) per month
- Step Therapy: Cervical Dystonia, Limb Spasticity:
ST Single Brand
Chronic Sialorrhea:
ST Single Generic
Migraine Prevention:
ST Multiple Generics
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