- Prior Authorization: Endometriosis:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Endometriosis:
Duration: 6 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Surgical Ablation to Prevent Recurrence Required: Yes
Reauthorization Requirement(s): Recurrence of symptoms
Documented Diagnosis: Yes
- Step Therapy: Endometriosis:
ST Single Generic
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