Kaiser Foundation Health Plan Northern California |
Spravato 28 Mg Spry (esketamine) |
Drugs for the Nervous System : Drugs for Depression |
- Step Therapy: Juvenile Idiopathic Arthritis:
ST Single Generic
- Quantity Limit: Limit 6 sprayers per month;QL(2 ea daily)
- Prior Authorization: Diabetic Medical Supplies:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
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