| Anthem Blue Cross (HMO, PPO, EPO) |
| Diastat AcuDial (diazepam) |
| Drugs for the Nervous System : Drugs for Seizures /Personality Disorder/Nerve Pain |
- May be covered under Medical Benefit.
- Quantity Limit: 4 pens per 28 day(s).
- Prior Authorization: PA Applies
- Step Therapy: Hemophilia B (Factor IX):
ST Multiple Brands
- 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; Dosing Limit: 1.25 mg per eye; each eye may be treated as frequently as every 4 weeks;
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