- Prior Authorization: Pain Narcotic: Opioid:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Orally administered anticancer medication.
Zero copay may apply.
Must be 35 or older and at increased risk for the first occurrence of breast cancer - after risk assessment and counseling.
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; Dosing Limit: 30 mg/kg once weekly;
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