| Anthem Blue Cross (HMO, PPO, EPO) |
| Trodelvy (sacituzumab govitecan-hziy) |
| Drugs for Cancer : Drugs for Cancer |
- Breast Cancer: Triple Negative:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Urothelial/Bladder Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 3 of Advanced disease;Metastatic disease;Previous treatment with a PD-1/PDL-1 inhibitor and platinum-containing chemotherapy;Urothelial carcinoma
ECOG Score Requirement Included in Policy: N/A
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;- PA Applies
- Prior Authorization: Documented Diagnosis: Yes
Duration: 1 year(s)
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