| Anthem Blue Cross (HMO, PPO, EPO) |
| Trulicity (dulaglutide) |
| Hormones : Drugs for Diabetes |
- Prior Authorization: CIDP: Immune Globulin:
PA Applies
Pemphigus Vulgaris:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
PID: Immune Globulin:
Duration: 6 Month(s)
- Prior Authorization: Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Bipolar:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Major Depressive Disorder:
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Documented Diagnosis: Yes
Psychiatry: Schizophrenia:
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Policy Requires Documentation of Patient Noncompliance to Oral Therapy: No
Established tolerability to oral formulation: No
Documented Diagnosis: Yes
- High Risk Medications require PA for members age 70 and older
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