Anthem Blue Cross (HMO, PPO, EPO)
Kyprolis (carfilzomib)
Drugs for Cancer : Drugs for Cancer
  • Multiple Myeloma:
    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 Clinical Pharmacology;FDA Approved Indications;NCCN Guidelines;Wolters Kluwer Lexi-Drugs
    ECOG Score Requirement in Policy: N/A
    ECOG status <=2: No
    Diagnosis Types: 2 of Patients who have received at least 2 prior regimens including a PI and an immunomodulatory agent;Refractory disease;Relapsed disease
    Concomitant Therapy Requirement: 1 of Dexamethasone and Sarclisa (isatuximab);in combination with daratumumab and dexamethasone;in combination with dexamethasone;in combination with lenalidomide and dexamethasone;in combination with panobinostat;in combination with pomalidomide and dexamethasone
    Policy Allows for Use as Combination Therapy: Yes
    Policy Allows for Use Monotherapy Therapy: No

    Waldenstrom Macroglobulinemia:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • PA Applies
  • Available only through Specialty Pharmacy; Limited access;
    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;
  • Prior Authorization: Documented Diagnosis: Yes
    Duration: 1 year(s)