- Step Therapy: Diabetes Type 2: DPP4 + Combo:
ST Single Generic
- Step Therapy: ST_APPLIES
- Quantity Limit: limit maximum 30 day(s) supply
- Prior Authorization: CIDP: Immune Globulin:
PA Applies
Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Duration: 6 Month(s)
Pemphigus Vulgaris, PID: Immune Globulin:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
|