- 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;
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