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
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