Anthem Blue Cross (HMO, PPO, EPO) |
Gonal-f (follitropin alfa) |
Hormones : Drugs for Women |
For FAX form click HERE Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites: Log in to Surescripts Log in to CoverMyMeds; For details on drug coverage click HERE;
- Quantity Limit: 204 strips per 30 day(s).
- Assisted Reproductive Technology (ART):
Age Requirement: >= 18
Duration: 30 Day(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Reproductive Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 30 day(s)
- Quantity Limit: 30 day supply per 1 fill(s).
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