| Anthem Blue Cross (HMO, PPO, EPO) |
| Copiktra (duvelisib) |
| Drugs for Cancer : Drugs for Cancer |
- May process through Pharmacy or Medical benefit depending on Patient location;
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: 2 tablets per 1 day(s).
- PA Applies
- Chronic Lymphocytic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Drug Policy Based On: Payer Specific
Diagnosis Types: Relapsed/refractory CLL or SLL after at least two prior therapies
Follicular Lymphoma (FL):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Prior Authorization: Chronic Lymphocytic Leukemia:
Documented Diagnosis: Yes
Duration: 1 year(s)
Reauthorization Required: Yes
Follicular Lymphoma (FL):
Documented Diagnosis: Yes
Duration: 1 year(s)
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