- May process through Pharmacy or Medical benefit depending on Patient location;
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;
- Quantity Limit: 4 capsules per 1 day(s).
- PA Applies
- Mantle Cell Lymphoma:
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Marginal Zone Lymphoma, Waldenstrom Macroglobulinemia:
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Prior Authorization: Mantle Cell Lymphoma:
Documented Diagnosis: Yes
Duration: 1 plan year
Marginal Zone Lymphoma, Waldenstrom Macroglobulinemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
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