Anthem Blue Cross (HMO, PPO, EPO)
Xermelo (telotristat ethyl)
Drugs for the Stomach : Drugs for Diarrhea
  • PA Applies
  • Quantity Limit: 3 tablets per 1 day(s).
  • Prior Authorization: PA Applies

  • 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;