| Anthem Blue Cross - 2014 to Present (HMO, PPO, EPO) |
| dextroamphetamine-amphetamine (dextroamphetamine-amphetamine) |
| Drugs for the Nervous System : Drugs for Sleep Disorder |
- Quantity Limit: limit maximum 10 ML PER fill retail
- Zero copay may apply.
- Low Testosterone:
Gender Requirement: Male
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: Unspecified
How Many Tests are Required to Confirm Diagnosis: = 3
Serum Total Testosterone Test Results: < 280
Free Testosterone Level Test Results: < 5
Patient must have symptoms of hypogonadism: Yes
Patient history of condition that may cause altered SHBG: Yes
Patient Must Not Have Untreated Sleep Apnea, Polycythemia or CHF: No
Diagnosis of Primary Hypogonadism or Hypogonadotropic Hypogonadisims: Yes
Documented Diagnosis: Yes
- Zero Copay;
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