- Prior Authorization: Diabetic Medical Supplies:
Documented Diagnosis: Yes
Duration: 12 Month(s)
- $0 copay.
- Quantity Limit: 15 tablets per 1 day(s).
- NSCLC EGFR Mutated:
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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