| Anthem Blue Cross (HMO, PPO, EPO) |
| Tysabri (natalizumab) |
| Drugs for the Nervous System : Drugs for Multiple Sclerosis |
- Crohn's Disease (CD):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: No
Multiple Sclerosis (MS):
Duration: 12 Month(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
- PA Applies
- Step Therapy: Crohn's Disease (CD):
ST Multiple Generics
- Quantity Limit: 1 vial per 28 day(s).
- 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;
- Prior Authorization: Crohn's Disease (CD):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Multiple Sclerosis (MS):
Duration: 12 Month(s)
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