- Quantity Limit: limit maximum 90 EA PER 30 day(s)
- Prior Authorization: Multiple Sclerosis (MS):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Secondary Progressive Multiple Sclerosis:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
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