Anthem Blue Cross (HMO, PPO, EPO)
Ixempra Kit (ixabepilone)
Drugs for Cancer : Drugs for Cancer
  • 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;
  • Breast Cancer: Hormone Refractory (HER2-):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 3 of FDA Approved Indications;NCCN Guidelines;Payer Specific
    Concomitant Use for HER2- with: 1 of capecitabine;N/A
    Diagnosis Types: 1 of HER2+ disease;HR+ and endocrine refractory;HR-;Recurrent or metastatic disease;Visceral Disease or Visceral Crisis
    Documented Concomitant Use for HER2+: trastuzumab

    Breast Cancer: HR+ (HER2-):
    Duration: 1 year(s)

    Breast Cancer: HR+ (HER2+):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • PA Applies
  • Prior Authorization: Breast Cancer: Hormone Refractory (HER2-), Breast Cancer: HR+ (HER2+):
    Documented Diagnosis: Yes
    Duration: 1 year(s)

    Breast Cancer: HR+ (HER2-):
    Duration: 1 year(s)