| Anthem Blue Cross (HMO, PPO, EPO) |
| Erwinase (asparaginase (Erwinia chrysan)) |
| Drugs for Cancer : Drugs for Cancer |
- Available only through Specialty Pharmacy;
- Prior Authorization: Acute Lymphoblastic Leukemia:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Acute Lymphoblastic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Diagnosis Types: Acute lymphoblastic leukemia
ECOG Score Requirement Included in Policy: N/A
Contraindications: Pancreatitis, thrombosis, hemorrhagic events
Specialty Pharmacy is Required: Y
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