| Anthem Blue Cross (HMO, PPO, EPO) |
| Zydelig (idelalisib) |
| Drugs for Cancer : Drugs for Cancer |
- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location;
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;
- Prior Authorization: Chronic Lymphocytic Leukemia:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Follicular Lymphoma (FL):
Documented Diagnosis: Yes
Duration: 1 Month(s)
Reauthorization Required: Yes
Marginal Zone Lymphoma:
Documented Diagnosis: Yes
Non Hodgkin Lymphoma (NHL):
Documented Diagnosis: Yes
Duration: 6 Month(s)
- Quantity Limit: 2 tablets per 1 day(s).
- Chronic Lymphocytic Leukemia:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Drug Policy Based On: Payer Specific
Diagnosis Types: 1 of CLL for relapsed/refractory disease;Small Lymphocytic Lymphoma
Follicular Lymphoma (FL):
Duration: 1 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Marginal Zone Lymphoma:
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Non Hodgkin Lymphoma (NHL):
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- PA Applies
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