| Anthem Blue Cross (HMO, PPO, EPO) |
| Ninlaro (ixazomib) |
| Drugs for Cancer : Drugs for Cancer |
- Quantity Limit: 2 tablets per 1 day(s).
- Diabetes Type 2: GLP1 + Combo:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Supporting Documentation Requirements: Medication History
- Ankylosing Spondylitis (AS):
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
Atopic Dermatitis (Eczema):
Age Requirement: >= 12
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Dermatologist;Immunologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Initial Authorization - POEM Values: N/A
Initial Authorization - SCORAD Values: N/A
Initial Authorization - EASI Values: N/A
Initial Authorization - IGA Values: N/A
Initial Authorization - PGA Values: N/A
Initial Authorization - ISGA Values: N/A
Initial Authorization - BSA Values: N/A
Physician Attestation for Initiation Required: No
Step Trial Length Period: Variable
Ulcerative Colitis (UC):
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
- Asthma (oral):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- PA_APPLIES
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