| Anthem Blue Cross (HMO, PPO, EPO) |
| Seroquel XR (T24d) (quetiapine) |
| Drugs for the Nervous System : Drugs for Severe Mental Disorders |
- Bipolar:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Major Depressive Disorder:
Duration: 1 year(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Documented Diagnosis: Yes
Psychiatry: Schizophrenia:
Duration: 1 year(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Policy Requires Documentation of Patient Noncompliance to Oral Therapy: No
Established tolerability to oral formulation: No
Documented Diagnosis: Yes
- Step Therapy: Psychiatry: Schizophrenia:
ST Multiple Generics
- Prior Authorization: Documented Diagnosis: Yes
Duration: 1 year(s)
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