| Sutter Health Plus |
| dimethyl fumarate (dimethyl fumarate) |
| Drugs for the Nervous System : Drugs for Multiple Sclerosis |
- Prior Authorization: PA_APPLIES
- ST_APPLIES
- Quantity Limit: limit maximum 5 mL PER 30 day(s)
- PA Applies
- Prior Authorization: Anemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Anemia due to Chemotherapy:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
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