- May process through Pharmacy or Medical benefit depending on Patient location;
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: 3 capsules per 1 day(s).
- PA Applies
- Prior Authorization: Documented Diagnosis: Yes
Duration: 1 year(s)
- Chronic Lymphocytic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 2 of Chronic Lymphocytic Leukemia;CLL for relapsed/refractory disease;CLL with or without 17p deletion;first line therapy;Small Lymphocytic Lymphoma
Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Graft Versus Host Disease (GVHD), Mantle Cell Lymphoma, Marginal Zone Lymphoma, Non Hodgkin Lymphoma (NHL), Waldenstrom Macroglobulinemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Step Therapy: Follicular Lymphoma (FL):
Step Therapy Applies
Graft Versus Host Disease (GVHD):
ST Single Generic
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