- Quantity Limit: 30 day supply per 1 fill(s).
- Prior Authorization: Migraine:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Migraine Prevention:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
- PA Required
- Quantity Limit: 200 units per 30 day(s).
- Quantity Limit: 113 grams per 30 day(s).
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