- Quantity Limit: limit maximum 4 EA PER 1 day(s)
- Prior Authorization: Multiple Sclerosis (MS):
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Secondary Progressive Multiple Sclerosis:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Multiple Sclerosis (MS):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
Secondary Progressive Multiple Sclerosis:
Age Requirement: >= 18
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 60 month(s)
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