| Anthem Blue Cross (HMO, PPO, EPO) |
| Enspryng (satralizumab-mwge) |
| Drugs for Organ Transplants : Drugs for Organ Transplants |
- Prior Authorization: Neuromyelitis Optica Spectrum Disorder:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Neuromyelitis Optica Spectrum Disorder:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Preferred Limited Distribution Network
Reauthorization Required: No
Duration of Reauthorization: N/A
- Quantity Limit: 1 syringe per 28 day(s).
- Available only through Specialty Pharmacy;
- Step Therapy: Neuromyelitis Optica Spectrum Disorder:
ST Multiple Generics
|