Anthem Blue Cross (HMO, PPO, EPO)
alogliptin (alogliptin)
Hormones : Drugs for Diabetes
  • Cytomegalovirus (CMV):
    Duration: 1 year(s)
    Documented Diagnosis: No
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • Quantity Limit: 1 kit / 28 days
  • Prior Authorization: PA Required
  • Anemia:
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Dialysis status: Patients on dialysis and not on dialysis
    Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
    Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL AND TSAT >= 20%
    Discontinuation requirements: No
    Reauthorization Requirements Iron Stores: serum ferritin >= 100 ng/mL AND TSAT >= 20%

    Anemia due to Chemotherapy:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): 1 of Hematologist;Oncologist
    Reauthorization Required: No
    Duration of Reauthorization: <= 6 month(s)
    Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
    Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL AND TSAT >= 20%
    Diagnosis Types: concomitant myelosuppresive chemotherapy
    Dose Increase Requirements: No
    Discontinuation requirements: No
    Reauthorization Requirements HgbHCT: 2 of Hgb <= 10 g/dL;Must show response to therapy with increase in Hgb >= 1 g/dL
    Reauthorization Requirements Iron Stores: serum ferritin >= 100 ng/mL AND TSAT >= 20%

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