Depen — Blue Cross Blue Shield of Alabama
severe active rheumatoid arthritis who have failed to respond to an adequate trial of conventional therapy
Preferred products
- generic penicillamine tablet
Initial criteria
- Patient must have ONE of the following:
- - A medication history of use in the past 90 days of ONE prerequisite agent OR
- - An intolerance or hypersensitivity to ONE prerequisite agent that is not expected to occur with the requested agent OR
- - A documented FDA labeled contraindication to ONE prerequisite agent that is not expected to occur with the requested agent
Approval duration
12 months