| Anthem Blue Cross (HMO, PPO, EPO) |
| Lupron Depot (3-Month) (leuprolide (3 month)) |
| Drugs for Cancer : Drugs for Cancer |
- Prior Authorization: Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
Juvenile Idiopathic Arthritis:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 2
Duration: 1 year(s)
Reauthorization Required: Yes
Psoriasis (PsO):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 4
Duration: 1 year(s)
- Quantity Limit: 200 units per 30 day(s).
- Prior Authorization: Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 7
Duration: 12 Month(s)
Reauthorization Required: Yes
- Zero copay may apply.
- Step Therapy: ST_APPLIES
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