Health Net
Evista (raloxifene)
Hormones : Drugs for Menopause and Bone Loss
  • Quantity Limit: limit maximum 3 EA PER fill retail
  • Bipolar:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Psychiatrist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Psychiatry: Schizophrenia:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Medical Test Required: No
    Specialist Type(s): Physiatrist
    Specialty Pharmacy Provider(s): AcariaHealth
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Policy Requires Documentation of Patient Noncompliance to Oral Therapy: Yes
    Established tolerability to oral formulation: Yes
    Documented Diagnosis: Yes

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