| Anthem Blue Cross (HMO, PPO, EPO) |
| Retevmo (selpercatinib) |
| Drugs for Cancer : Drugs for Cancer |
- Available through Specialty Pharmacy;
- Multiple Sclerosis (MS):
Duration: 12 Month(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
- Low Testosterone:
Age Requirement: >= 18
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
How Many Tests are Required to Confirm Diagnosis: >= 2
Serum Total Testosterone Test Results: < 300
Free Testosterone Level Test Results: N/A
Patient must have symptoms of hypogonadism: No
Patient history of condition that may cause altered SHBG: No
Patient Must Not Have Untreated Sleep Apnea, Polycythemia or CHF: No
Supporting Documentation Requirements: 2 of Chart Notes;Lab Tests
Reauthorization Supporting Documentation Requirements: Successful response to therapy
Diagnosis of Primary Hypogonadism or Hypogonadotropic Hypogonadisims: Yes
Documented Diagnosis: Yes
- PA Applies
- Oral Anti-Cancer drug
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