| Anthem Blue Cross - 2014 to Present (HMO, PPO, EPO) |
| Kadcyla (ado-trastuzumab emtansine) |
| Drugs for Cancer : Drugs for Cancer |
- PA_APPLIES
- ST_APPLIES
- CIDP: Immune Globulin:
Duration: 12 week(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Progressive or Relapsing Disease Course Required: No
Electrodiagnostic Evidence of Demyelination Required: Yes
Supporting Documentation Requirements: Medical Tests
PID: Immune Globulin:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Documented inability to mount an immune response: Yes
Documentation of severe infection despite prophylactic ABX treatment: No
Documented Serum IgG Level: Unspecified
IgG Subclass Level Referencing Standard Deviation Below Age Adjusted Mean: > 2
Supporting Documentation Requirements: Medical Tests
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