- PA_APPLIES
- Quantity Limit: 6 packets per 1 day(s).
- Prior Authorization: Acute Migraine, Migraine:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Migraine Prevention: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 3 Month(s)
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
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