| Anthem Blue Cross (HMO, PPO, EPO) |
| thiotepa (thiotepa) |
| Drugs for Cancer : Drugs for Cancer |
- Quantity Limit: limit maximum 3 EA PER fill retail
- Anemia:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
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: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
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: 4 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
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