- Quantity Limit: limit maximum 60 EA PER 30 day(s)
- Prior Authorization: Assisted Reproductive Technology (ART):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 30 Day(s)
Reauthorization Required: Yes
- Prior Authorization: Hepatocellular Carcinoma:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Kidney Cancer:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 30 EA PER 30 day(s)
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