Anthem Blue Cross (HMO, PPO, EPO) |
Votrient (pazopanib) |
Drugs for Cancer : Drugs for Cancer |
- Quantity Limit: 3 tablets per 1 day(s).
- ST_APPLIES
- PA Required
- Available only through Specialty Pharmacy;
- Migraine:
Age Requirement: >= 18
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Migraine Frequency: 4 per month
Is supporting documentation required for initial approval: No
Is supporting documentation required for re-approval: No
Policy Contains Verbiage for Botulinum Interchangeability: No
Diagnosis of Chronic Migraine Required: No
Required Decrease in Duration of Chronic Migraine for Reauthorization: N/A
Provider Responsibility Language Referenced in Policy: No
Dose Conversion Language Included in Policy: No
Reauthorization Criteria Includes 50% Reduction Language: No
Reauthorization Criteria Includes 7 Day100 Hour Reduction Language: No
Retreatment Language Included in Policy: N/A
Policy Contains ICHD2 or ICHD3 Language: No ICHD2 or ICHD3 criteria exist
Migraine Prevention: Age Requirement: >= 18
Duration: 3 Month(s)
Documented Diagnosis: Yes
- Quantity Limit: limit maximum 30 mL PER 365 day(s)
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