| Anthem Blue Cross (HMO, PPO, EPO) |
| sodium benzoate-sod phenylacet (sodium benzoate-sod phenylacet) |
| Drugs that Alter Metabolism : Drugs that Alter Metabolism |
- Prior Authorization: Urea Cycle Disorder:
Duration: 1 year(s)
- Step Therapy: Urea Cycle Disorder:
ST Multiple Generics
- Urea Cycle Disorder:
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
|