| Anthem Blue Cross (HMO, PPO, EPO) |
| Abilify (aripiprazole) |
| Drugs for the Nervous System : Drugs for Severe Mental Disorders |
- Quantity Limit: 1 tablet per 1 day(s).
- Prior Authorization: Bipolar:
Documented Diagnosis: Yes
Age Requirement: >= 6
Duration: 1 year(s)
Psychiatry: Schizophrenia:
Age Requirement: > 5
Duration: 12 Month(s)
- Step Therapy: ST Single Generic
- Bipolar:
Age Requirement: >= 6
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Major Depressive Disorder:
Age Requirement: > 5
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: No
Documented Diagnosis: No
Psychiatry: Schizophrenia:
Age Requirement: > 5
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: No
Policy Requires Documentation of Patient Noncompliance to Oral Therapy: No
Established tolerability to oral formulation: No
Documented Diagnosis: No
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