- Quantity Limit: Yes. Maximum quantity 7 tablets per Rx at retail. X3 at mail.
- Prior Authorization: Thrombocytopenia In Chronic Liver Disease:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 Month(s)
- Thrombocytopenia In Chronic Liver Disease:
Duration: 1 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
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