- Quantity Limit: limit maximum 3 EA PER 1 day(s)
- Prior Authorization: Pain Narcotic: Opioid:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
- Step Therapy: Assisted Reproductive Technology (ART):
ST Single Brand
- Quantity Limit: limit maximum 30 EA PER 30 day(s)
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