Anthem Blue Cross (HMO, PPO, EPO) |
Spravato (56 MG Dose) (esketamine) |
Drugs for the Nervous System : Drugs for Depression |
- Prior Authorization: Neurogenic Detrusor Overactivity (NDO):
Documented Diagnosis: Yes
Age Requirement: >= 3
Duration: 12 Month(s)
Reauthorization Required: Yes
- Step Therapy: ST_APPLIES
- Quantity Limit: 1 tablet per 1 day(s).
- Prior Authorization: PA Applies
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
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