Anthem Blue Cross (HMO, PPO, EPO) |
Alecensa (alectinib) |
Drugs for Cancer : Drugs for Cancer |
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: PA Required
- Multiple Sclerosis (MS):
Age Requirement: >= 2
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 month(s)
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
Supporting Documentation Requirements: 3 of Chart Notes;Documentation of baseline number of relapses per year;Documentation of expanded disability status scale (EDSS) score;Lab Tests
- Orally administered anticancer medication.
- Quantity Limit: limit maximum 1 GM PER 30 day(s)
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