| Anthem Blue Cross (HMO, PPO, EPO) |
| Xalkori (crizotinib) |
| Drugs for Cancer : Drugs for Cancer |
- Prior Authorization: PA_APPLIES
- Step Therapy: Diabetic Medical Supplies:
ST Multiple Brands
- Quantity Limit: 4 tablets per 1 day(s).
- Quantity Limit: limit maximum 6 EA PER 1 day(s)
- Chorea in Huntington's Disease:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Tardive Dyskinesia (TD):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
AIMS Score: N/A
Patient Must Not Have Congenital LQTS or Arrhythmias Associated with Prolonged QT Interval: No
Patient Must Not Have Risk of Suicidal Behavior and Unstable Psychiatric Symptoms: No
Concomitant Use With Other VMAT inhibitors Prohibited: No
Supporting Documentation Requirements: 1 of Lab Tests;Medication History
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