| Anthem Blue Cross - 2014 to Present (HMO, PPO, EPO) |
| Hemlibra (emicizumab-kxwh) |
| Drugs for the Blood : Drugs for the Blood |
- PA_APPLIES
- Quantity Limit: 2 inhalers per 30 day(s).
- Diffuse Large B-Cell Lymphoma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Multiple Myeloma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of All NCCN indications with evidence level of 2A or higher;in combination with dexamethasone for the treatment of relapsed or refractory multiple myeloma who have received at least four prior therapies and refractory to at least two proteasome inhibitors at least two immunomodulatory agents,and an anti-CD38 monoclonal antibody
Concomitant Therapy Requirement: in combination with dexamethasone
- Step Therapy: Derm: Acne Vulgaris:
ST Generic and Brand
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