Anthem Blue Cross (HMO, PPO, EPO) |
Kisqali Femara (400 MG Dose) (ribociclib-letrozole) |
Drugs for Cancer : Drugs for Cancer |
- Quantity Limit: 8 capsules per 1 day(s).
- Quantity Limit: 4 tablets per 1 day(s).
- Quantity Limit: 2 vials per 6 day(s).
- PA Applies
- Neurology: Epilepsy:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Type(s): Partial-Onset Seizures
Used as Adjunctive Treatment: No
Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: N/A
Documented history of persisting seizures after titration to highest tolerated dose of each AED.: Yes
Lack of compliance as a reason for treatment failure has been ruled out: Yes
Documentation of treatment failure due to intolerable side effects.: Yes
Positive Response to Therapy Required for Reauth: No
Treatment for Age 17 years or older: No
Treatment for Age 1-16 years old: No
History of >= to 30 day trial of other AED required: No
Reapproval based on response: No
|