- Prior Authorization: PA Applies
- Prior Authorization: Diabetic Medical Supplies:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
- Quantity Limit: limit maximum 200 EA PER 30 day(s)
- Prior Authorization: Glaucoma:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
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