- Step Therapy: Diabetes Type 2: GLP1 + Combo:
ST Single Generic
- Prior Authorization: Diabetes Type 2: GLP1 + Combo:
Documented Diagnosis: Yes
Age Requirement: >= 10
Duration: 1 year(s)
Reauthorization Required: Yes
- Diabetes Type 2: GLP1 + Combo:
Age Requirement: >= 10
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
- PA Required
- Quantity Limit: 30 day supply per 1 fill(s).
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