- Prior authorization required. Member should try alternative(s) before submitting a prior authorization. If approved, covered at appropriate tier under the member's pharmacy benefit. Prior authorization required age 30 and up.
- Prior Authorization: Prior authorization required. Member should try alternative(s) before submitting a prior authorization. If approved, covered at appropriate tier under the member's pharmacy benefit. Prior authorization required age 30 and up.
- Quantity Limit: Maximum quantity of 45 GM per prescription. x3 at mail.
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