Anthem Blue Cross (HMO, PPO, EPO)
Gazyva (obinutuzumab)
Drugs for Cancer : Drugs for Cancer
  • Chronic Lymphocytic Leukemia:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: NCCN Guidelines
    Concomitant Therapy Requirement: 1 of Acalabrutinib;bendamustine;chlorambucil;Venetoclax
    Diagnosis Types: 1 of as a single agent for relapsed/refractory without 17p deletion;CLL with or without 17p deletion;first line in combination with chlorambucil for disease without deletion 17p/TP53 mutation;first line, as a single agent;Previously untreated CLL;Small Lymphocytic Lymphoma

    Follicular Lymphoma (FL), Non Hodgkin Lymphoma (NHL):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • PA Applies
  • 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;
  • Prior Authorization: Documented Diagnosis: Yes
    Duration: 1 year(s)