| Anthem Blue Cross (HMO, PPO, EPO) |
| Actemra ACTPen (tocilizumab) |
| Drugs for Pain and Fever : Arthritis and Pain Drugs |
- PA Applies
- Step Therapy: Rheumatoid Arthritis (RA):
ST Multiple Brands
- Quantity Limit: 4 autoinjectors per 28 day(s).
- Giant Cell Arteritis:
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Juvenile Idiopathic Arthritis:
Age Requirement: >= 2
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: Yes
Rheumatoid Arthritis (RA):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
- Prior Authorization: Giant Cell Arteritis:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Juvenile Idiopathic Arthritis:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 2
Duration: 1 year(s)
Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
- 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;
|