| Anthem Blue Cross (HMO, PPO, EPO) |
| Austedo (deutetrabenazine) |
| Drugs for the Nervous System : Drugs for the Nervous System |
- Assisted Reproductive Technology (ART):
Age Requirement: >= 18
Duration: 30 Day(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Reproductive Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 30 day(s)
- Quantity Limit: limit maximum 6 EA PER 1 day(s)
- PA Applies
- Quantity Limit: 1 pack (91 tablets) per 28 days
- Quantity Limit: 1 capsule per 1 day(s).
- Quantity Limit: 1 capsule per 1 day(s).
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