Kaiser Foundation Health Plan Northern California
Erivedge (vismodegib)
Drugs for Cancer : Drugs for Cancer
  • Quantity Limit: limit maximum 120 GM PER 30 day(s)
  • Prior Authorization: Cryopyrin-Associated Periodic Syndromes (CAPS):
    Age Requirement: >= 12
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Recurrent Pericarditis :
    Documented Diagnosis: Yes
    Age Requirement: >= 12
    Duration: 6 Month(s)
    Reauthorization Required: Yes

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