| Anthem Blue Cross (HMO, PPO, EPO) |
| Makena (hydroxyprogesterone cap(ppres)) |
| Hormones : Drugs for Women |
- PA Required
- Prior Authorization: Peanut Allergy:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 4
Duration: 1 year(s)
Reauthorization Required: Yes
- PA Applies
- Multiple Myeloma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of For newly diagnosed or Primary treatment of multiple myeloma;patients who have received at least one prior therapy
Concomitant Therapy Requirement: in combination with dexamethasone
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