- Prior Authorization: Ultra Low Dose Oral Contraceptives:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
- Preventive Drug: $0 copay.
- Ultra Low Dose Oral Contraceptives:
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
- Step Therapy: Ultra Low Dose Oral Contraceptives:
ST Multiple Generics
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