- Prior Authorization: Diabetes Type 2: DPP4 + Combo:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
- Prior Authorization: PA_APPLIES
- Quantity Limit: 1 tablet per 1 day(s).
- Quantity Limit: 1 EA per 1 fill(s).
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