Anthem Blue Cross (HMO, PPO, EPO) |
Imcivree (setmelanotide) |
Drugs for Eating Disorders : Drugs for Eating Disorders |
- PA Applies
- Quantity Limit: 9 vials per 30 day(s).
- Prior Authorization: Obesity due to Pathogenic Variants:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 16 week(s)
Reauthorization Required: Yes
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;
- Obesity due to Pathogenic Variants:
Age Requirement: >= 6
Duration: 16 week(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 16 week(s)
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