| Anthem Blue Cross (HMO, PPO, EPO) |
| Monoferric (ferric derisomaltose) |
| Drugs for Nutrition : Drugs for Nutrition |
- Prior Authorization: Anemia:
Documented Diagnosis: Yes
Duration: 3 Month(s)
- PA Applies
- Step Therapy: Anemia:
ST Single Generic
- Quantity Limit: 1 vial per 1 day(s).
- Anemia:
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Dialysis status: not on dialysis
Initial Therapy Iron Stores Requirements: 1 of Bone marrow demonstrates inadequate iron stores;Serum ferritin < 100 ng/mL;Serum ferritin <=500 ng/mL and TSAT < = 30%;TSAT < 20%
Discontinuation requirements: No
- 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;
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