- 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: limit maximum 0.30 ML PER 1 day(s)
- Step Therapy: Diabetes Type 2: GLP1 + Combo:
ST Single Generic
- 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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