| Anthem Blue Cross (HMO, PPO, EPO) |
| Nulibry (fosdenopterin) |
| Drugs for Metabolic Disease : Drugs for Metabolic Disease |
- Prior Authorization: PA Applies
- Quantity Limit: limit maximum 200 EA PER 30 day(s)
- Prior Authorization: Lennox Gastaut Syndrome (LGS):
Duration: 12 Month(s)
Reauthorization Required: Yes
Neurology: Epilepsy:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 2 EA PER 1 day(s)
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