- Quantity Limit: 1 vial per 28 day(s).
- Prior Authorization: Cluster Seizure/Seizure Emergency:
Documented Diagnosis: Yes
Age Requirement: >= 6
Duration: 6 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Prior Authorization: Acute Lymphoblastic Leukemia:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
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