- Prior Authorization: Assisted Reproductive Technology (ART):
Documented Diagnosis: Yes
Duration: 3 Month(s)
- Assisted Reproductive Technology (ART):
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Step Therapy: Assisted Reproductive Technology (ART):
ST Single Brand
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