| Anthem Blue Cross (HMO, PPO, EPO) |
| Mononine 500 (+/-) Unit Kit (coagulation factor IX) |
| Drugs for the Blood : Drugs to Prevent Bleeding |
- Prior Authorization: Hemophilia B (Factor IX):
Duration: 1 year(s)
- Step Therapy: Hemophilia B (Factor IX):
ST Multiple Brands
- Hemophilia B (Factor IX):
Duration: 1 year(s)
Documented Diagnosis: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Dosing Limit(s): N/A
Treatment Center Required: No
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