| Anthem Blue Cross (HMO, PPO, EPO) |
| leuprolide (leuprolide) |
| Drugs for Cancer : Drugs for Cancer |
- Crohn's Disease (CD):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Gastroenterologist
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 month(s)
TB Test required: No
Multiple Sclerosis (MS):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
Supporting Documentation Requirements: 2 of Chart Notes;Lab Tests
- Prior Authorization: Neurology: Epilepsy:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
- Quantity Limit: limit maximum 30 EA PER 30 day(s)
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