Anthem Blue Cross (HMO, PPO, EPO)
SymlinPen 120 (pramlintide)
Hormones : Drugs for Diabetes
  • Prior Authorization: PA Required
  • Juvenile Idiopathic Arthritis, Rheumatoid Arthritis (RA):
    Age Requirement: >= 2
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    TB Test required: No

    Psoriasis (PsO):
    Age Requirement: >= 2
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Dermatologist;Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    TB Test required: No
    History of Plaque Psoriasis: N/A
    Overall % of Body Surface For Initiation: N/A
    Overall % of Body Surface For Initiation With Sensitive Areas: N/A
    Sensitive Area BSA Percent override: No

  • Quantity Limit: 50 grams per 30 day(s).
  • Quantity Limit: 4 capsules per 1 day(s).
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