| Anthem Blue Cross (HMO, PPO, EPO) |
| Adcetris (brentuximab vedotin) |
| 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;
- Prior Authorization: CD-30 Mediated Peripheral T-Cell Lymphoma, Hodgkin Lymphoma (HL), Systemic Anaplastic Large Cell Lymphoma:
Documented Diagnosis: Yes
Duration: 1 year(s)
Cutaneous T-Cell Lymphomas:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
- CD-30 Mediated Peripheral T-Cell Lymphoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): CVS Specialty
Reauthorization Required: No
Duration of Reauthorization: N/A
Cutaneous T-Cell Lymphomas:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Hodgkin Lymphoma (HL):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Systemic Anaplastic Large Cell Lymphoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
- PA Applies
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