| Anthem Blue Cross (HMO, PPO, EPO) |
| deferasirox (deferasirox) |
| Drugs for Overdose or Poisoning : Drugs for Overdose or Poisoning |
- Quantity Limit: limit maximum 60 EA PER 30 day(s)
- Quantity Limit: limit maximum 3 EA PER 1 day(s)
- Prior Authorization: Uterine Fibroids:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
|