- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Prior Authorization: Endometriosis:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- 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
- Step Therapy: Endometriosis:
ST Multiple Generics
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