| Anthem Blue Cross (HMO, PPO, EPO) |
| Humira Pen-Psor/Uveit Starter (adalimumab) |
| Drugs for Pain and Fever : Arthritis and Pain Drugs |
- PA Applies
- Hidradenitis Suppurativa (HS):
Age Requirement: >= 12
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): CVS Specialty
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Psoriasis (PsO):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: 3
Overall % of Body Surface For Initiation With Sensitive Areas: 3
Psoriasis Classification: chronic.,moderate to severe
Sensitive Area BSA Percent override: No
Uveitis:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Step Therapy: ST Single Generic
- Prior Authorization: Hidradenitis Suppurativa (HS):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 12
Duration: 1 year(s)
Reauthorization Required: Yes
Psoriasis (PsO):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
Uveitis:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Quantity Limit: 1 kit per 365 day(s).
- 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;
|