| Anthem Blue Cross (HMO, PPO, EPO) |
| Margenza (margetuximab-cmkb) |
| Drugs for Cancer : Drugs for Cancer |
- Quantity Limit: limit maximum 200 EA PER 30 day(s)
- Quantity Limit: limit maximum 1 EA PER 25 day(s)
- Step Therapy: Adult Onset Stills Disease (AOSD), Juvenile Idiopathic Arthritis, Periodic Fever Syndromes:
ST Single Generic
Gouty Arthritis:
ST Multiple Generics
- Endometrial Cancer:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Hepatocellular Carcinoma:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Oncologist
Duration of Reauthorization: Unspecified
Diagnosis Types: 2 of All FDA-approved indications;Hepatocellular Cancer;NCCN recommended level 2a-b or better
ECOG Score Requirement Included in Policy: N/A
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