Anthem Blue Cross (HMO, PPO, EPO) |
Kazano (alogliptin-metformin) |
Hormones : Drugs for Diabetes |
- Quantity Limit: limit maximum 3 EA PER fill retail
- CD-30 Mediated Peripheral T-Cell Lymphoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): CVS Specialty
Reauthorization Required: No
Duration of Reauthorization: N/A
Cutaneous T-Cell Lymphomas: Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Hodgkin Lymphoma (HL): Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Systemic Anaplastic Large Cell Lymphoma: Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
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