| Anthem Blue Cross (HMO, PPO, EPO) |
| Releuko (filgrastim-ayow) |
| Drugs for the Blood : Drugs for the Blood |
- Neutropenia:
Duration: 1 year(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Risk Factor for Developing Febrile Neutropenia (FN): 1 of Age greater than 65 years;Bone marrow involvement;Extensive prior chemotherapy/radiation therapy;Liver dysfunction;Open wounds;Poor performance status;Poor renal function;Pre-existing neutropenia
Documented Diagnosis: Yes
Criteria includes risk factor for developing FN: 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;
- PA Applies
- Step Therapy: Neutropenia:
ST Single Brand
- Prior Authorization: Neutropenia:
PA Applies
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