- Step Therapy: Diabetes Type 2: GLP1 + Combo:
ST Single Generic
- Diabetes Type 2: GLP1 + Combo:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Supporting Documentation Requirements: Medication History
- Quantity Limit: 4 pens (2mL) per 28 days
- Prior Authorization: Diabetes Type 2: GLP1 + Combo:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
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