Anthem Blue Cross (HMO, PPO, EPO)
DayVigo (lemborexant)
Drugs for the Nervous System : Drugs for Insomnia
  • Prior Authorization: Osteoarthritis: OA of the Knee:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Hepatocellular Carcinoma:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Duration of Reauthorization: = 12 month(s)
    Diagnosis Types: 2 of Hepatocellular Cancer;Metastatic disease;Unresectable disease
    ECOG Score Requirement Included in Policy: N/A

    Kidney Cancer:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Drug Policy Based On: NCCN Guidelines
    ECOG Score Requirement Included in Policy: N/A
    Policy Includes Reference to Coverage for Non Clear Cell Histology: No
    If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
    Concomitant Use With: 1 of Afinitor (everolimus);Keytruda

    Thyroid Carcinoma:
    Duration: 12 Month(s)


  • 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;
  • Ankylosing Spondylitis (AS), Crohn's Disease (CD), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    TB Test required: No

    Psoriasis (PsO):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    TB Test required: No
    History of Plaque Psoriasis: N/A
    Overall % of Body Surface For Initiation: N/A
    Overall % of Body Surface For Initiation With Sensitive Areas: N/A
    Sensitive Area BSA Percent override: No