| Anthem Blue Cross - 2014 to Present (HMO, PPO, EPO) |
| Quillivant XR (methylphenidate HCl) |
| Drugs for the Nervous System : Drugs for Attention Deficit Disorder |
- Chronic Lymphocytic Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 1 of All FDA-approved indications;CLL for relapsed/refractory disease
Diffuse Large B-Cell Lymphoma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Quantity Limit: limit maximum 120 GM PER 25 day(s)
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