| Anthem Blue Cross (HMO, PPO, EPO) |
| Palynziq (pegvaliase-pqpz) |
| Drugs that Alter Metabolism : Drugs that Alter Metabolism |
- Available only through Specialty Pharmacy;
- Phenylketonuria (PKU):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
- Quantity Limit: 2 syringes per 1 day(s).
- Prior Authorization: Phenylketonuria (PKU):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
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