| Anthem Blue Cross (HMO, PPO, EPO) |
| Emgality (300 MG Dose) (galcanezumab-gnlm) |
| Drugs for the Nervous System : Drugs for Migraine Headaches |
- Prior Authorization: Cluster Headache:
Documented Diagnosis: Yes
Duration: 3 Month(s)
Reauthorization Required: Yes
Migraine Prevention:
Documented Diagnosis: Yes
Duration: 3 Month(s)
- Step Therapy: Cluster Headache:
ST Single Generic
Migraine Prevention:
ST Multiple Generics
- PA Applies
- Cluster Headache:
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
Migraine Prevention:
Duration: 3 Month(s)
Documented Diagnosis: Yes
- Quantity Limit: 3 syringes per 28 day(s).
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;
|