Anthem Blue Cross (HMO, PPO, EPO) |
diclofenac submicronized (diclofenac submicronized) |
Drugs for Pain and Fever : Arthritis and Pain Drugs |
- Quantity Limit: limit maximum 3 EA PER fill retail
- Step Therapy: ST_APPLIES
- May be covered under Medical Benefit.
- Psoriasis (PsO):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: Yes
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: 5
Overall % of Body Surface For Initiation With Sensitive Areas: Unspecified
Psoriasis Classification: Moderate-Severe
Sensitive Area BSA Percent override: Yes
- COPD (oral):
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
COPD associated with chronic bronchitis: No
History of COPD exacerbation: No
Documented Diagnosis: Yes
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