| Anthem Blue Cross (HMO, PPO, EPO) |
| Soliris (eculizumab) |
| Drugs for the Blood : Drugs for the Blood |
- PA Applies
- Myasthenia Gravis:
Age Requirement: >= 18
Duration: 26 week(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Neuromyelitis Optica Spectrum Disorder:
Age Requirement: >= 18
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Paroxysmal Nocturnal Hemoglobinuria:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
- Prior Authorization: Myasthenia Gravis:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 26 week(s)
Reauthorization Required: Yes
Neuromyelitis Optica Spectrum Disorder:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Reauthorization Required: Yes
Paroxysmal Nocturnal Hemoglobinuria:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 6 Month(s)
- Quantity Limit: 8 vials per 28 day(s).
- Step Therapy: Myasthenia Gravis:
ST Multiple Generics
- Available only through Specialty Pharmacy;
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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