Sutter Health Plus
Imvexxy Maintenance Pack (estradiol)
Hormones : Drugs for Women
  • 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).