| Anthem Blue Cross (HMO, PPO, EPO) |
| Dexilant (dexlansoprazole) |
| Drugs for the Stomach : Drugs for Ulcers and Stomach Acid |
- ST Applies
- Erosive Esophagitis:
Age Requirement: <= 1
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Gastroesophageal Reflux Disease:
Age Requirement: <= 1
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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 |For details on quantity limit coverage click HERE
;- Prior Authorization: Erosive Esophagitis:
Age Requirement: <= 1
Gastroesophageal Reflux Disease:
Age Requirement: <= 1
Duration: 1 year(s)
- Step Therapy: ST Single Generic
- Quantity Limit: 1 capsule per 1 day(s).
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