- Quantity Limit: 1 tablet per 1 day(s).
- Prior Authorization: Central Precocious Puberty:
Documented Diagnosis: Yes
Endometriosis:
Documented Diagnosis: Yes
Duration: 6 Month(s)
- Prior Authorization: Antiviral: Hepatitis C (HCV):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 3
Duration: 24 week(s)
Reauthorization Required: Yes
- Step Therapy: ST_APPLIES
- Quantity Limit: limit maximum 8 mL PER 1 day(s)
- Step Therapy: Diabetic Medical Supplies:
ST Single Brand
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