| Sutter Health Plus |
| Drizalma Sprinkle (duloxetine) |
| Drugs for the Nervous System : Drugs for Seizures /Personality Disorder/Nerve Pain |
- Quantity Limit: 0.05 units per 1 day(s).
- Prior Authorization: Diabetic Medical Supplies:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
- Quantity Limit: 3 capsules per 1 day(s).
- Quantity Limit: limit maximum 2 EA PER 1 day(s)
- Prior Authorization: Graft Versus Host Disease (GVHD):
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 12 Month(s)
Reauthorization Required: Yes
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