Anthem Blue Cross (HMO, PPO, EPO)
Trodelvy (sacituzumab govitecan-hziy)
Drugs for Cancer : Drugs for Cancer
  • Hemophilia A or B with Inhibitor:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    Dosing Limit(s): Unspecified
    Treatment Center Required: No
    Dosing Limits Exist: No

  • Prior Authorization: Chronic Lymphocytic Leukemia, Mantle Cell Lymphoma:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes

    Marginal Zone Lymphoma, Waldenstrom Macroglobulinemia:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Prior Authorization: Chronic Lymphocytic Leukemia, Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Graft Versus Host Disease (GVHD), Granulomatosis with Polyangiitis, Marginal Zone Lymphoma, Microscopic Polyangiitis (MPA), Non Hodgkin Lymphoma (NHL), Pemphigus Vulgaris, Waldenstrom Macroglobulinemia:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Immune Thrombocytopenic Purpura (ITP):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Multiple Sclerosis (MS):
    Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

    Myasthenia Gravis, Uveitis:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Rheumatoid Arthritis (RA):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: 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;