| Anthem Blue Cross (HMO, PPO, EPO) |
| Firdapse (amifampridine phosphate) |
| Drugs for Nerves and Muscles : Drugs for Nerves and Muscles |
- Lambert-Eaton Myasthenic Syndrome (LEMS):
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): 1 of Accredo Health Group, Inc.;Apothecary By Design;Circle Care;The Pharmacy at Maine Medical Center
Reauthorization Required: No
Duration of Reauthorization: N/A
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: 8 tablets per 1 day(s).
- Prior Authorization: Lambert-Eaton Myasthenic Syndrome (LEMS):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 3 Month(s)
- PA Applies
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