| Anthem Blue Cross (HMO, PPO, EPO) |
| Gonal-F 37.5 Unit Solr (follitropin alfa) |
| Hormones : Drugs for Women |
- Prior Authorization: Assisted Reproductive Technology (ART):
Documented Diagnosis: Yes
Duration: 1 year(s)
- Assisted Reproductive Technology (ART):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
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