- Derm: Acne Vulgaris:
Duration: 12 Month(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Limited to non-cosmetic use: No
Topical Psoriasis:
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: No
Documented Diagnosis: No
- Quantity Limit: limit maximum 30 day(s) supply
- Quantity Limit: 204 lancets per 30 day(s).
- Prior Authorization: Obesity:
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 12 week(s)
Reauthorization Required: Yes
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