Anthem Blue Cross - 2014 to Present (HMO, PPO, EPO)
Kitabis Pak (tobramycin with nebulizer)
Drugs for the Lungs : Drugs for Cystic Fibrosis
  • Quantity Limit: limit maximum 30 day(s) supply
  • PA Applies
  • Quantity Limit: 5 tablets per 1 day(s).
  • Multiple Myeloma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: NCCN Guidelines
    ECOG Score Requirement in Policy: N/A
    ECOG status <=2: No
    Diagnosis Types: 2 of All NCCN indications with evidence level of 2A or higher;Multiple Myeloma;Patients who have received at least 2 prior regimens including a PI and an immunomodulatory agent;patients who have received at least one prior therapy;patients with disease progression on or within 60 days of completion of the last therapy
    Concomitant Therapy Requirement: 1 of in combination with cyclophosphamide and dexamethasone;in combination with dexamethasone;in combination with lenalidomide and dexamethasone;in combination with pomalidomide and dexamethasone

  • PA_APPLIES
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