| Anthem Blue Cross (HMO, PPO, EPO) |
| Takhzyro (lanadelumab-flyo) |
| Drugs for the Heart : Drugs for the Heart |
- Hereditary Angioedema (HAE):
Age Requirement: >= 12
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
Diagnosis Type(s): 1 of Hereditary Angioedema;Prophylaxis against Acute HAE Attacks;Short term prophylaxis before a medical/surgical or dental procedure
HAE Type: Unspecified
Documented Lab Values: 2 of Low C1-INH Antigenic Level;Low C1-INH Functional Level;Low C4 Level
History of Moderate or Severe Attacks: Yes
- Quantity Limit: 1 vial per 28 day(s).
- Prior Authorization: Hereditary Angioedema (HAE):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 12
Duration: 6 Month(s)
Reauthorization Required: Yes
- 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;
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