- Quantity Limit: 204 strips per 30 day(s).
- Zero Copay;
- Prior Authorization: Uveal Melanoma:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Quantity Limit: 2 grams per 1 day(s).
- Quantity Limit: limit maximum 60 EA PER 30 day(s)
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