Anthem Blue Cross (HMO, PPO, EPO)
Diastat AcuDial (diazepam)
Drugs for the Nervous System : Drugs for Seizures /Personality Disorder/Nerve Pain
  • Quantity Limit: 2 syringes per 1 fill(s).
  • Cluster Seizure/Seizure Emergency:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • 5 Fills per 30 days;
  • Prior Authorization: Cluster Seizure/Seizure Emergency:
    Documented Diagnosis: Yes
    Duration: 1 year(s)

  • Step Therapy: Cluster Seizure/Seizure Emergency:
    ST Multiple Generics

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