| Anthem Blue Cross (HMO, PPO, EPO) |
| Danyelza (naxitamab-gqgk) |
| Drugs for Cancer : Drugs for Cancer |
- Cryopyrin-Associated Periodic Syndromes (CAPS):
Age Requirement: >= 12
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Recurrent Pericarditis :
Age Requirement: >= 12
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
- Quantity Limit: limit maximum 20 EA PER 30 day(s)
- Quantity Limit: 1 tablet per 1 day(s).
- Prior Authorization: PA_APPLIES
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