- Cluster Headache:
Age Requirement: >= 18
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Migraine Prevention:
Age Requirement: >= 18
Duration: 3 Month(s)
Documented Diagnosis: Yes
- Anemia:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Dialysis status: Patients on dialysis and not on dialysis
Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL AND TSAT >= 20%
Discontinuation requirements: No
Reauthorization Requirements Iron Stores: serum ferritin >= 100 ng/mL AND TSAT >= 20%
Anemia due to Chemotherapy:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: No
Duration of Reauthorization: <= 6 month(s)
Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL AND TSAT >= 20%
Diagnosis Types: concomitant myelosuppresive chemotherapy
Dose Increase Requirements: No
Discontinuation requirements: No
Reauthorization Requirements HgbHCT: 2 of Hgb <= 10 g/dL;Must show response to therapy with increase in Hgb >= 1 g/dL
Reauthorization Requirements Iron Stores: serum ferritin >= 100 ng/mL AND TSAT >= 20%
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;- Quantity Limit: 1 capsule per 1 day(s).
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