| Anthem Blue Cross (HMO, PPO, EPO) |
| Humira Pen-CD/UC/HS Starter (adalimumab) |
| Drugs for the Stomach : Drugs for Inflammatory Bowel Disease |
- Crohn's Disease (CD):
Age Requirement: >= 6
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
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
Ulcerative Colitis (UC):
Age Requirement: >= 5
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
- 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;
- Step Therapy: ST Single Generic
- PA Applies
- Prior Authorization: Crohn's Disease (CD):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 1 year(s)
Reauthorization Required: Yes
Hidradenitis Suppurativa (HS):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 12
Duration: 1 year(s)
Reauthorization Required: Yes
Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 5
Duration: 1 year(s)
Reauthorization Required: Yes
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