| Anthem Blue Cross (HMO, PPO, EPO) |
| Mylotarg (gemtuzumab ozogamicin) |
| Drugs for Cancer : Drugs for Cancer |
- Prior Authorization: Short Bowel Syndrome:
Documented Diagnosis: Yes
Age Requirement: >= 1
Duration: 7 Month(s)
Reauthorization Required: Yes
- Prior Authorization: Cystic Fibrosis (CF):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Must use AcariaHlth Sp Rx. Anti-Cancer:Maximum $200 copayment per State Law.
- Prior Authorization: Sickle Cell Disease:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 5
Duration: 1 year(s)
- Preventive Drug: Zero copay. Grand Fathered Plans at Tier 2;
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