- Prior Authorization: Osteoarthritis: OA of the Knee:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 1 GM PER 30 day(s)
- Quantity Limit: limit maximum 0.50 mL PER 1 day(s)
- Quantity Limit: 30 day supply per 1 fill(s).
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