To view the current medical policy, please click the link below:
To view previous versions of this policy that are now expired, please click on the links below:
Currently, there are no previous versions of this policy.
|Rev#:||Date:||Nature of Change:|
|1.0||02/23/2018||Removed 90-Day Provider Notification for Gonal-f. The policy is on hold for now.|
|1.1||06/29/2018||Added a link to the new 90-Day Provider Notification for Gonal-f.|
|1.2||10/24/2018||Added a link to the current policy effective 10/1/18. The 90-day notice was removed.|
Files that are in PDF format can be viewed using the free Adobe Reader or another PDF-reader application.
Need a language interpreter?
ʻŌlelo Hawaiʻi | Bisaya | 繁體中文 | Ilokano | 日本語 | 한국어 | ພາສາລາວ | Kajin Ṃajōḷ | Lokaiahn Pohnpei | Gagana Sāmoa | Español | Tagalog | Tonga | Foosun Chuuk | Tiếng Việt