- Step Therapy: Endometriosis:
ST Multiple Generics
- Prior Authorization: Endometriosis:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Quantity Limit: Maximum quantity of 31 per 31 Day(s). Maximum quantity 1 tablet per day.
- Endometriosis:
Duration: 6 Month(s)
Specialist Required: Yes
Medical Test Required: No
Specialist Type(s): 1 of Endocrinologist;Gynecologist;Obstetrician
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Surgical Ablation to Prevent Recurrence Required: No
Reauthorization Requirement(s): 2 of Bone mineral density within normal limits;Positive response to therapy
Documented Diagnosis: Yes
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