| Anthem Blue Cross (HMO, PPO, EPO) |
| Arcalyst (rilonacept) |
| Drugs for Pain and Fever : Arthritis and Pain Drugs |
- 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;
- PA Applies
- Quantity Limit: 4 vials per 28 day(s).
- Cryopyrin-Associated Periodic Syndromes (CAPS):
Age Requirement: >= 12
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Recurrent Pericarditis :
Age Requirement: >= 12
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
- Prior Authorization: Cryopyrin-Associated Periodic Syndromes (CAPS):
Age Requirement: >= 12
Duration: 1 year(s)
Reauthorization Required: Yes
Recurrent Pericarditis :
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 1 year(s)
Reauthorization Required: Yes
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