| Anthem Blue Cross (HMO, PPO, EPO) |
| dihydroergotamine (dihydroergotamine) |
| Drugs for the Nervous System : Drugs for Migraine Headaches |
- Step Therapy: Neutropenia:
ST Single Brand
- Prior Authorization: Diabetic Medical Supplies:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 15 mL PER 30 day(s)
- Quantity Limit: 1 tablet per 1 day(s).
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