| Anthem Blue Cross (HMO, PPO, EPO) |
| SymlinPen 60 (pramlintide) |
| Hormones : Drugs for Diabetes |
- Step Therapy: Cystic Fibrosis (CF):
ST Multiple Generics
- COPD (oral):
Age Requirement: >= 18
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
COPD associated with chronic bronchitis: No
History of COPD exacerbation: No
Documented Diagnosis: Yes
- Quantity Limit: limit maximum 70 ML PER fill mail
- QL (180 day supply per 365 days;
- Diffuse Large B-Cell Lymphoma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Multiple Myeloma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of All NCCN indications with evidence level of 2A or higher;in combination with dexamethasone for the treatment of relapsed or refractory multiple myeloma who have received at least four prior therapies and refractory to at least two proteasome inhibitors at least two immunomodulatory agents,and an anti-CD38 monoclonal antibody
Concomitant Therapy Requirement: in combination with dexamethasone
- Step Therapy: Thyroid Carcinoma:
ST Single Brand
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