- Step Therapy: Derm: Acne Vulgaris:
ST Single Generic
- Quantity Limit: limit maximum 60 EA PER 30 day(s)
- Prior Authorization: Endometriosis:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Metastatic Prostate Cancer, Non-Metastatic Prostate Cancer, Uterine Fibroids:
Documented Diagnosis: Yes
- Reduction of CV events in CAD/PAD:
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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