- Hemophilia A (Factor VIII):
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Dosing Limit(s): N/A
Treatment Center Required: No
Von Willebrand Disease: Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Dosing Limit(s): N/A
Treatment Center Required: No
Dosing Limits Exist: No
- QL (300 per Rx);
- Quantity Limit: Limit 528gms per month;QL(17.6 gm daily)
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