- Prior Authorization: MAC Lung Disease:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- MAC Lung Disease:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Infectious Disease Specialist;Pulmonologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Step Therapy: MAC Lung Disease:
ST Multiple Generics
- Quantity Limit: limit maximum 8.40 ML PER 1 day(s)
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