| Anthem Blue Cross (HMO, PPO, EPO) |
| Dojolvi (triheptanoin) |
| Drugs for Nutrition : Drugs for Nutrition |
- PA_APPLIES
- Prior Authorization: Gastro: IBS-D:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Step Therapy: ST_APPLIES
- Prior Authorization: Diabetic Medical Supplies:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
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;
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