| Anthem Blue Cross (HMO, PPO, EPO) |
| Mycapssa (octreotide acetate) |
| Hormones : Drugs for Growth |
- Quantity Limit: 4 capsules per 1 day(s).
- Acromegaly:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
- Prior Authorization: Acromegaly:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
|