- PA Required
- Quantity Limit: 14 capsules per 365 day(s).
- Oral Anti-Cancer drug
- Ophthalmic: Dry Eye:
Age Requirement: >= 17
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Supporting Documentation Requirements: Chart Notes
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