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;- May be covered under Medical Benefit.
- PA Required
- 1. FDA Approved Indications: For the treatment of moderate to severe dementia of the Alzheimer`s type in patients stabilized on: a. memantine hydrochloride (10 mg twice daily or 28 mg extendedrelease once daily) and donepezil hydrochloride 10 mg. b. memantine hydrochloride (5 mg twice daily or 14 mg extended release once daily) and donepezil hydrochloride 10 mg (in patients with severe renal impairment). 2. Health Net Approved Indications and Usage Guidelines: a. Diagnosis of moderate to severe dementia AND; b. Medical justification must be provided why individual generic components of donepezil and memantine cannot be used. 3. Authorization Limit: Length of Benefit.
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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