Anthem Blue Cross (HMO, PPO, EPO)
Empaveli (pegcetacoplan)
Drugs for the Blood : Drugs for the Blood
  • Paroxysmal Nocturnal Hemoglobinuria:
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 year(s)

  • PA Applies
  • Prior Authorization: Paroxysmal Nocturnal Hemoglobinuria:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes


  • 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: limit maximum 200 mL PER 30 day(s)
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