- Derm: Acne Vulgaris:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Limited to non-cosmetic use: No
- PA_APPLIES
- Step Therapy: Urea Cycle Disorder:
ST Single Generic
- Prior Authorization: Hypertension (High Blood Pressure):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
|