Anthem Blue Cross (HMO, PPO, EPO)
Uroxatral (alfuzosin)
Drugs for the Urinary System : Drugs for the Prostate
  • Quantity Limit: limit maximum 3 EA PER fill retail
  • Blepharospasm:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Ophthalmologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Cervical Dystonia:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist;Physiatrist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Chronic Sialorrhea:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Appropriate Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: <= 12 month(s)

    Limb Spasticity:
    Age Requirement: >= 2
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedic Specialist;Physiatrist
    Reauthorization Required: No
    Duration of Reauthorization: = 12 month(s)

    Migraine:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Pain Management Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    Migraine Frequency: 15 per month
    Is supporting documentation required for initial approval: Yes
    Is supporting documentation required for re-approval: No
    Policy Contains Verbiage for Botulinum Interchangeability: No
    Diagnosis of Chronic Migraine Required: Yes
    Required Decrease in Duration of Chronic Migraine for Reauthorization: Unspecified
    Provider Responsibility Language Referenced in Policy: No
    Dose Conversion Language Included in Policy: No
    Reauthorization Criteria Includes 50% Reduction Language: No
    Reauthorization Criteria Includes 7 Day100 Hour Reduction Language: No
    ICHD2ICHD3 Language Included in Policy: at least 15 days per month with headaches lasting four hours a day or longer
    Retreatment Language Included in Policy: N/A
    Policy Contains ICHD2 or ICHD3 Language: ICHD2 criteria exist

    Migraine Prevention:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Specialist Type(s): 1 of Neurologist;Pain Management Specialist

    Neurogenic Detrusor Overactivity (NDO):
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Urologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Overactive Bladder:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Urologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Diagnosis Types: Overactive bladder with urge urinary incontinence, urgency, or frequency

    Pediatric Upper Limb Spasticity:
    Age Requirement: >= 2
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist;Physiatrist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Primary Axillary Hyperhidrosis:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Dermatologist;Neurologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Policy Contains Verbiage for Botulinum Interchangeability: No
    Documented Diagnosis: Yes

    Spasticity: Adult:
    Age Requirement: >= 2
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Spasticity: Lower Limb:
    Age Requirement: >= 1
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist
    Reauthorization Required: Yes
    Duration of Reauthorization: >= 12 month(s)

    Spasticity: Upper Limb:
    Age Requirement: >= 2
    Duration: 12 week(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 week(s)

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