| Anthem Blue Cross (HMO, PPO, EPO) |
| Arzerra (ofatumumab) |
| Drugs for Cancer : Drugs for Cancer |
- PA Applies
- Chronic Lymphocytic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Concomitant Therapy Requirement: 1 of chlorambucil;fludarabine and cyclophosphamide
Diagnosis Types: 2 of as a single agent;CLL for relapsed/refractory disease;extended use in complete/partial response after >= 2 lines of therapy for recurrent/progressive CLL;first line in combination with chlorambucil where fludarabine therapy is inappropriate;Small Lymphocytic Lymphoma
- 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: Chronic Lymphocytic Leukemia:
Documented Diagnosis: Yes
Duration: 1 year(s)
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