| Anthem Blue Cross (HMO, PPO, EPO) |
| Ruxience (rituximab-pvvr) |
| Drugs for Pain and Fever : Arthritis and Pain Drugs |
- Prior Authorization: Documented Diagnosis: Yes
Duration: 1 year(s)
- Step Therapy: ST Single Brand
- Graft Versus Host Disease (GVHD), Secondary Progressive Multiple Sclerosis:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Immune Thrombocytopenic Purpura (ITP):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Types: Immune Thrombocytopenic Purpura
Required Medical Information: 2 of Documentation of diagnosis;Medication History
Supporting Documentation Must Be Submitted: Yes
Multiple Sclerosis (MS):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
- PA Applies
- 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; Dosing Limit: See clinical criteria for details;
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