| Anthem Blue Cross (HMO, PPO, EPO) |
| Eligard (leuprolide) |
| Drugs for Cancer : Drugs for Cancer |
- Prior Authorization: PA Required
- Quantity Limit: 30 containers per 30 day(s).
- OAC;
- Anemia:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Dialysis status: Patients on dialysis and not on dialysis
Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL AND TSAT >= 20%
Discontinuation requirements: No
Reauthorization Requirements Iron Stores: serum ferritin >= 100 ng/mL AND TSAT >= 20%
Anemia due to Chemotherapy:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: No
Duration of Reauthorization: <= 6 month(s)
Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL AND TSAT >= 20%
Diagnosis Types: concomitant myelosuppresive chemotherapy
Dose Increase Requirements: No
Discontinuation requirements: No
Reauthorization Requirements HgbHCT: 2 of Hgb <= 10 g/dL;Must show response to therapy with increase in Hgb >= 1 g/dL
Reauthorization Requirements Iron Stores: serum ferritin >= 100 ng/mL AND TSAT >= 20%
- PA Required
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