Anthem Blue Cross (HMO, PPO, EPO)
Vyondys 53 (golodirsen)
Drugs for Nerves and Muscles : Drugs for Nerves and Muscles
  • PA Applies

  • 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; Dosing Limit: 30 mg/kg once weekly;
  • Prior Authorization: Duchenne Muscular Dystrophy (DMD):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 6
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Duchenne Muscular Dystrophy (DMD):
    Age Requirement: >= 6
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    Specialty Pharmacy is Required: Not Defined