| Anthem Blue Cross (HMO, PPO, EPO) |
| Talzenna (talazoparib) |
| Drugs for Cancer : Drugs for Cancer |
- Respiratory Syncytial Virus (RSV):
Duration: 5 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Prior Authorization: Reduction of CV events in CAD/PAD:
Duration: 1 year(s)
- Chronic Lymphocytic Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: Payer Specific
Supporting Documentation Requirements: Lab Tests
Diagnosis Types: 1 of CLL for relapsed/refractory disease;Small Lymphocytic Lymphoma
Mantle Cell Lymphoma:
Age Requirement: > 19
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Psoriasis (PsO):
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Dermatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: 3
Overall % of Body Surface For Initiation With Sensitive Areas: 3
Psoriasis Classification: Moderate-Severe
Sensitive Area BSA Percent override: No
Psoriatic Arthritis (PsA):
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Dermatologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
- Pain Narcotic: Opioid:
Duration: 1 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Used for Cancer Patients: No
Around-The-Clock Analgesic Required: No
Morphine Equivalent Dose (MED) Limit: <= 90 mg/day
Morphine Equivalent Dose (MED) Required: Yes
|