- Quantity Limit: limit maximum 120 EA PER 30 day(s)
- Quantity Limit: limit maximum 8 EA PER 30 day(s)
- Hemophilia A (Factor VIII):
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Dosing Limit(s): N/A
Treatment Center Required: No
- Prior Authorization: Anxiety:
Duration: 1 year(s)
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