- Step Therapy: Gastro: IBS-C:
Step Applies
- Quantity Limit: limit maximum 20 EA PER 180 day(s)
- Prior Authorization: PA Applies
- Antiviral: HIV:
Duration: 1 year(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Approved Indication Type(s) Included in Policy (HIV vs PrEP): HIV Only
Restriction to use in combo with other ARVs: Yes
Policy Required Patient Type: Naive vs. Treatment-Experienced: Treatment Experienced
Documented Viral Load Assay Required for PA Renewals: No
Documented Diagnosis: Yes
Restriction to Use For Active HIV Indication Only: Yes
Restriction to Use For PrEP Indication Only: No
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