Anthem Blue Cross (HMO, PPO, EPO)
Spravato (84 MG Dose) (esketamine)
Drugs for the Nervous System : Drugs for Depression
  • Quantity Limit: limit maximum 1 EA PER 1 day(s)

  • 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 Quantity drug coverage click HERE;
  • Step Therapy: Diabetes Type 2: Short Acting Insulin (Meal-time):
    ST Multiple Generics

  • Available only through Specialty Pharmacy;
  • Multiple Sclerosis (MS):
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Neurologist
    Reauthorization Required: Yes
    Duration of Reauthorization: <= 12 month(s)
    Patients Cardiac Medical History Required: No
    Concomitant use of other MS medication: No
    Supporting Documentation Requirements: 4 of Chart Notes;Documentation of baseline number of relapses per year;Documentation of expanded disability status scale (EDSS) score;Lab Tests;Medication History

    Secondary Progressive Multiple Sclerosis:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Neurologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)