Anthem Blue Cross (HMO, PPO, EPO)
Fabrazyme (agalsidase beta)
Drugs for Metabolic Disease : Drugs for Metabolic Disease
  • Prior Authorization: Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Ophthalmic: Allergic Conjunctivitis:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • ST_APPLIES
  • Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA):
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

    Crohn's Disease (CD):
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Gastroenterologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

    Nonradiographic Axial Spondyloarthritis:
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Psoriasis (PsO):
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Dermatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No
    History of Plaque Psoriasis: N/A
    Overall % of Body Surface For Initiation: 3
    Overall % of Body Surface For Initiation With Sensitive Areas: 3
    Psoriasis Classification: Moderate-Severe
    Sensitive Area BSA Percent override: No

    Psoriatic Arthritis (PsA):
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Dermatologist;Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

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