| Anthem Blue Cross (HMO, PPO, EPO) |
| Besponsa (inotuzumab ozogamicin) |
| Drugs for Cancer : Drugs for Cancer |
- Quantity Limit: 1 vial per 1 day(s).
- Prior Authorization: PA Applies
- Prior Authorization: Bipolar:
Documented Diagnosis: Yes
Age Requirement: >= 10
Duration: 1 plan year
Reauthorization Required: Yes
Psychiatry: Schizophrenia:
Documented Diagnosis: Yes
Age Requirement: >= 13
Duration: 1 plan year
Reauthorization Required: Yes
- Neutropenia:
Age Requirement: >= 18
Duration: 6 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
Dosing Limit Defined In Policy: 2 of 6mg;Per chemotherapy cycle
Billing Note(s): HCPCS Code/ JCode Required
Documented Diagnosis: Yes
Criteria includes risk factor for developing FN: No
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