- Quantity Limit: 204 strips per 30 day(s).
- Prior Authorization: Migraine:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Migraine Prevention: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
- Prior Authorization: PA_APPLIES
|