| Anthem Blue Cross (HMO, PPO, EPO) |
| Riabni (rituximab-arrx) |
| Drugs for Cancer : Drugs for Cancer |
- Quantity Limit: limit maximum 2.70 GM PER 30 day(s)
- ST_APPLIES
- Prior Authorization: Cystic Fibrosis (CF):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 12 Month(s)
Reauthorization Required: Yes
- Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
Juvenile Idiopathic Arthritis:
Age Requirement: >= 2
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: No
Psoriatic Arthritis (PsA):
Age Requirement: >= 18
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
- Quantity Limit: limit maximum 240 EA PER 30 day(s)
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