| Anthem Blue Cross (HMO, PPO, EPO) |
| Vitrakvi (larotrectinib) |
| Drugs for Cancer : Drugs for Cancer |
- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location; 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; Split Fill;
- Solid Tumor with NTRK Gene Fusion:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Specialty Pharmacy is Required: Not Defined
- Prior Authorization: Solid Tumor with NTRK Gene Fusion:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
- PA Applies
- Quantity Limit: limit maximum 10 mL PER 1 day(s)
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