- Quantity Limit: limit maximum 2 EA PER 1 day(s)
- Prior Authorization: PA Applies
- 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
- Quantity Limit: 1 tablet per 1 day(s).
- Quantity Limit: 30 day supply per 1 fill(s).
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