- Step Therapy Applies
- Quantity Limits Apply
- Prior Authorization: Diabetic Peripheral Neuropathy:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Diabetic Peripheral Neuropathy:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
|