| Anthem Blue Cross (HMO, PPO, EPO) |
| Prolia (denosumab) |
| Hormones : Drugs for Menopause and Bone Loss |
- Prior Authorization: Lupus Nephritis:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Systemic Lupus Erythematosus (SLE):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 5
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: 1 capsule per 1 day(s).
- Zero copay may apply.
- Quantity Limit: 50 grams per 30 day(s).
- Quantity Limit: 5 injections per 30 day(s).
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