Health Net
Follistim AQ (Soln) (follitropin beta)
Hormones : Drugs for Women
  • Prior Authorization: Assisted Reproductive Technology (ART):
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Gender Requirement: Female
    Duration: 30 Day(s)
    Reauthorization Required: Yes

  • Assisted Reproductive Technology (ART):
    Age Requirement: >= 18
    Duration: 30 Day(s)
    Gender Requirement: Female
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Reproductive Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: >= 30 day(s)