| Anthem Blue Cross (HMO, PPO, EPO) |
| Iclusig (ponatinib) |
| Drugs for Cancer : Drugs for Cancer |
- PA_APPLIES
- Metastatic Castrate-Sensitive Prostate Cancer (mCSPC):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): 1 of Avella Specialty Pharmacy;Optum Specialty Pharmacy
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Metastatic Prostate Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Quantity Limit: 1 pack per 365 day(s).
- Prior Authorization: PA_APPLIES
- Quantity Limit: limit maximum 30 day(s) supply
|