| Anthem Blue Cross (HMO, PPO, EPO) |
| Firvanq (vancomycin) |
| Drugs for Infections : Antibiotics |
- Prior Authorization: Clostridium Difficile-Associated Diarrhea/Infection (CDAD/CDI):
Documented Diagnosis: Yes
Duration: 3 Month(s)
- Quantity Limit: limit maximum 1,200 mL PER 30 day(s)
- Clostridium Difficile-Associated Diarrhea/Infection (CDAD/CDI):
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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