| Anthem Blue Cross (HMO, PPO, EPO) |
| Imfinzi (durvalumab) |
| Drugs for Cancer : Drugs for Cancer |
- Prior Authorization: Documented Diagnosis: Yes
Duration: 1 year(s)
- NSCLC Systemic Therapy:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Small Cell Lung Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
ECOG Score Requirement Included in Policy: N/A
Diagnosis Types: 3 of First line treatment;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;Small Cell Lung Cancer
Concomitant Therapy Requirement: 1 of carboplatin and etoposide;cisplatin and etopside
- 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;
- PA Applies
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