- Quantity Limit: limit maximum 3 EA PER fill retail
- Bipolar:
Age Requirement: >= 10
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Psychiatry: Schizophrenia:
Age Requirement: >= 18
Duration: 1 plan year
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Policy Requires Documentation of Patient Noncompliance to Oral Therapy: No
Established tolerability to oral formulation: No
Documented Diagnosis: Yes
- Quantity Limit: 100 grams per 30 day(s).
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