| Anthem Blue Cross - 2014 to Present (HMO, PPO, EPO) |
| Kesimpta (ofatumumab) |
| Drugs for the Nervous System : Drugs for Multiple Sclerosis |
- Quantity Limit: limit maximum 4 EA PER 365 day(s)
- Chemo-induced Nausea and Vomiting (CINV):
Age Requirement: >= 18
Duration: 3 Day(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: >= 3 day(s)
NV associated with highly emetogenic cancer chemotherapy (HEC): No
NV associated with moderately emetogenic cancer chemotherapy (MEC): No
Concomitant therapy with Corticosteroid: No
Concomitant therapy with 5-HT3 Antagonist: No
HIV Wasting:
Age Requirement: >= 18
Duration: 6 Month(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Prior Authorization: Endometrial Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Hepatocellular Carcinoma, Kidney Cancer:
Documented Diagnosis: Yes
Duration: 1 year(s)
Thyroid Carcinoma:
Duration: 1 year(s)
- Quantity Limit: 9 tablets per 30 day(s).
- Preventive Drug: Zero copay. Grand Fathered Plans at Tier 2;
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