- Quantity Limit: 200 syringes per 30 day(s).
- Quantity Limit: 204 strips per 30 day(s).
- Hemophilia A (Factor VIII):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Dosing Limit(s): N/A
Treatment Center Required: No
|