Anthem Blue Cross (HMO, PPO, EPO)
zoledronic ac-mannitol-0.9NaCl (zoledronic ac-mannitol-0.9NaCl)
Hormones : Drugs for Menopause and Bone Loss
  • Quantity Limit: limit maximum 1 EA PER 1 day(s)
  • Anemia:
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Dialysis status: Patients on dialysis and not on dialysis
    Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
    Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL OR TSAT >= 20% OR bone marrow demonstrates adequate iron stores
    Discontinuation requirements: Yes
    Documentation Requirements: blood pressure is adequately controlled before initiation and during therapy
    Titration Requirements: 1 of Maintain Hgb = 10 g/dL for non-dialysis patients;Maintain Hgb range 10 - 11 g/dL for dialysis patients

    Anemia due to Chemotherapy:
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
    Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL OR TSAT >= 20% OR bone marrow demonstrates adequate iron stores
    Diagnosis Types: 3 of anticipated outcome of chemotherapy is not cure;concomitant myelosuppresive chemotherapy;minimum of two additional months of planned chemotherapy;non-myeloid malignancy
    Dose Increase Requirements: No
    Discontinuation requirements: Yes

  • Quantity Limit: 1 inhaler per 30 day(s).