Anthem Blue Cross - 2014 to Present (HMO, PPO, EPO)
dextroamphetamine (dextroamphetamine)
Drugs for the Nervous System : Drugs for Sleep Disorder

  • 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: limit maximum 1 GM PER 30 day(s)
  • QL (60 per Rx);
  • Osteoporosis: Post Menopausal Women:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    History of Fracture Required: Variable
    BMD T-score at neck, total hip, or lumbar spine: <= -3
    Self-Administration Allowed: No
    Multiple fractures required: No
    Documented Diagnosis: Yes

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