- 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): 2 of Recurrence of symptoms;Used in combination with add-back therapy
Documented Diagnosis: Yes
Uterine Fibroids:
Duration: 3 Month(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Requirement(s): 3 of Anemia associated with Uterine Fibroids;Non-responsive to iron therapy;Preoperative treatment as adjunct to surgery
Documented Diagnosis: Yes
- Prior Authorization: NSAIDs for Arthritis:
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 12 Month(s)
Reauthorization Required: Yes
- May be covered under Medical Benefit.
- Quantity Limit: 204 lancets per 30 day(s).
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