Anthem Blue Cross (HMO, PPO, EPO)
Truxima (rituximab-abbs)
Drugs for Cancer : Drugs for Cancer
  • Graft Versus Host Disease (GVHD), Secondary Progressive Multiple Sclerosis:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Granulomatosis with Polyangiitis:
    Age Requirement: >= 2
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialty Pharmacy Provider(s): IngenioRx Specialty Pharmacy
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Immune Thrombocytopenic Purpura (ITP):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Diagnosis Types: Immune Thrombocytopenic Purpura
    Required Medical Information: 2 of Documentation of diagnosis;Medication History
    Supporting Documentation Must Be Submitted: Yes

    Microscopic Polyangiitis (MPA):
    Age Requirement: >= 2
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Multiple Sclerosis (MS):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Patients Cardiac Medical History Required: No
    Concomitant use of other MS medication: No

    Myasthenia Gravis:
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Pemphigus Vulgaris:
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialty Pharmacy Provider(s): IngenioRx Specialty Pharmacy
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Rheumatoid Arthritis (RA):
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    TB Test required: No

  • Prior Authorization: Graft Versus Host Disease (GVHD), Immune Thrombocytopenic Purpura (ITP), Multiple Sclerosis (MS), Secondary Progressive Multiple Sclerosis:
    Documented Diagnosis: Yes
    Duration: 1 year(s)

    Granulomatosis with Polyangiitis, Microscopic Polyangiitis (MPA):
    Documented Diagnosis: Yes
    Age Requirement: >= 2
    Duration: 1 year(s)

    Myasthenia Gravis, Pemphigus Vulgaris, Rheumatoid Arthritis (RA):
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 1 year(s)

  • PA Applies
  • 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: See clinical criteria for details;
  • Step Therapy: Graft Versus Host Disease (GVHD), Immune Thrombocytopenic Purpura (ITP), Secondary Progressive Multiple Sclerosis:
    ST Single Brand

    Myasthenia Gravis:
    ST Multiple Generics

    Rheumatoid Arthritis (RA):
    ST Multiple Brands

<< Return | Back to top