| Anthem Blue Cross (HMO, PPO, EPO) |
| Ilaris (canakinumab (PF)) |
| Drugs for Pain and Fever : Arthritis and Pain Drugs |
- Quantity Limit: 2 vials per 28 day(s).
- Adult Onset Stills Disease (AOSD):
Age Requirement: >= 2
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Cryopyrin-Associated Periodic Syndromes (CAPS):
Age Requirement: >= 4
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Periodic Fever Syndromes:
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
- Step Therapy: ST Single Generic
- Prior Authorization: Adult Onset Stills Disease (AOSD):
Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 1 year(s)
Reauthorization Required: Yes
Cryopyrin-Associated Periodic Syndromes (CAPS):
Age Requirement: >= 4
Duration: 1 year(s)
Reauthorization Required: Yes
Periodic Fever Syndromes:
Medical Test Required: Yes
Duration: 1 year(s)
Reauthorization Required: Yes
- PA Applies
- Available only through Specialty Pharmacy; Limited access;
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;
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