Anthem Blue Cross (HMO, PPO, EPO)
Glucotrol XL (glipizide)
Hormones : Drugs for Diabetes
  • Quantity Limit: limit maximum 3 EA PER fill retail
  • Osteoarthritis: OA of the Knee:
    Duration: 1 year(s)
    Documented Diagnosis: No
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Elapsed Duration Since Previous Course of Therapy: N/A

  • Ankylosing Spondylitis (AS):
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    TB Test required: No

    Psoriatic Arthritis (PsA):
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Dermatologist;Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    TB Test required: No

    Rheumatoid Arthritis (RA):
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    TB Test required: No

    Ulcerative Colitis (UC):
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Gastroenterologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    TB Test required: No

  • Step Therapy: COPD (oral):
    Serevent Diskus and Striverdi Respimat
  • PA_APPLIES
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