Anthem Blue Cross (HMO, PPO, EPO)
Avsola (infliximab-axxq)
Drugs for Pain and Fever : Arthritis and Pain Drugs
  • 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;
  • Step Therapy: Ankylosing Spondylitis (AS), Psoriasis (PsO):
    ST Generic and Brand

    Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA):
    ST Multiple Generics

  • Prior Authorization: Ankylosing Spondylitis (AS), Psoriasis (PsO), Psoriatic Arthritis (PsA):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 1 year(s)

    Crohn's Disease (CD), Ulcerative Colitis (UC):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 6
    Duration: 1 year(s)
    Reauthorization Required: Yes

    Rheumatoid Arthritis (RA):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 1 year(s)
    Reauthorization Required: Yes

    Uveitis:
    Documented Diagnosis: Yes
    Duration: 1 year(s)

  • PA Applies
  • Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA):
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    TB Test required: Yes

    Crohn's Disease (CD), Ulcerative Colitis (UC):
    Age Requirement: >= 6
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    TB Test required: Yes

    Psoriasis (PsO):
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    TB Test required: Yes
    History of Plaque Psoriasis: N/A
    Overall % of Body Surface For Initiation: 3
    Overall % of Body Surface For Initiation With Sensitive Areas: N/A
    Sensitive Area BSA Percent override: No

    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

    Uveitis:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

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