Gonal-f Rff

75 UNIT — VIAL (EA)

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

1 plan

Source: Excel (XLSX) · Formulary date: Sep 23, 2026 · Checked: 8 hours, 52 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 2 - Brand Formulary	✓	—	✓ GONAL-F RFF 75 UNITS VIAL TO BE DISPENSED AT A MAX QTY OF 48 UNITS IN 22 DAYS OR 48 UNITS IN 23 DAYS	PA \| QL PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED; Quantity limit