Anthem Blue Cross (HMO, PPO, EPO) |
Ixempra Kit (ixabepilone) |
Drugs for Cancer : Drugs for Cancer |
- Diabetes Type 1: Insulin Pumps:
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Duration Since Comprehensive Diabetes Educations Program Completed: N/A
Number of Daily Meal Time Short Acting Injections Required to Intiate Therapy: >= 3
Duration of Type 1 Pharma Therapy Required to Initiate Product: N/A
Documented Diagnosis: Yes
Diabetic Medical Supplies: Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
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;
- Quantity Limit: limit maximum 1.14 GM PER 1 day(s)
- Growth Hormone Deficiency:
Duration: 12 Month(s)
Specialist Required: Yes
Specialist Type(s): Endocrinologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Pediatric Growth Hormone Deficiency (GHD) Requirement(s): 3 of Bone Age Required;Delayed Skeletal Maturation Required;Diagnosis of Pediatric Growth Hormone Deficiency;Growth Velocity Required;Height > 2 standard deviations (SD) below mean for age and gender;Height is > 2.25 standard deviations below population mean (< 1.2 percentile for age and gender) utilizing age and gender growth charts;Height Standard Deviation Score Required;History of Neonatal Hypoglycemia Required;Insulin Growth Factor Binding Protein-3 (IGFBP-3) Level Required;Insulin-like Growth Factor 1 (IGF-1/Somatomedin-C) Level Required;Tanner stage < 4
Pediatric - GH Stimulation Test: = 2
Pediatric - Pituitary Hormone Deficiency: Unspecified
Pediatric - Reauthorization Requirement(s): 3 of Expected adult height has not been reached;Increase in growth rate;Other requirement(s)
Adult Growth Hormone Deficiency Requirement(s): 3 of Cannot be used in combination with Androgens;Cannot be used in combination with Aromatase Inhibitors;Diagnosis of Adult-onset Growth Hormone Deficiency (GHD);Diagnosis of Childhood-onset Growth Hormone Deficiency (GHD);Insulin-like Growth Factor 1 (IGF-1/Somatomedin-C) Level Required
Adult - GHD Stimulation Test: = 1
Adult - Pituitary Hormone Deficiency: = 3
Adult - Duration of Initial Authorization: = 12 month(s)
Adult - Reauthorization Requirement(s): 2 of Cannot be used in combination with Androgens;Cannot be used in combination with Aromatase Inhibitors;Diagnosis of panhypopituitarism;Insulin-like Growth Factor 1 (IGF-1) Required
Adult - Duration of Reauthorization: = 12 month(s)
Documented Diagnosis of Other Approved Indications: 1 of Chronic Renal Insufficiency;Growth Failure in Children Born Small for Gestational Age (SGA);Noonan Syndrome;Prader-Willi Syndrome in Children (PWS);Short Stature Homeobox-Containing Gene (SHOX);Turner's Syndrome (TS)
Documented Diagnosis: Yes
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