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(Note: Members under 65 years of age are not subject to the prior authorization The requested medication is medically necessary and the clinical benefits outweigh the risks for zolpidem this specific patient .
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Does patient require higher dosage (quantity limit exception)? ►If yes, indicate quantity requested: per 30 days OR quantity The number of doses available under the dose restriction for the prescription drug has zolpidem been ineffective in the treatment of the enrollee’s disease or medical condition .

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