| Anthem Blue Cross (HMO, PPO, EPO) |
| Saphnelo (anifrolumab-fnia) |
| Drugs for Organ Transplants : Drugs for Organ Transplants |
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: Systemic Lupus Erythematosus (SLE):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Quantity Limit: 1 vial per 28 day(s).
- PA Applies
- Systemic Lupus Erythematosus (SLE):
Age Requirement: >= 18
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
Positive Autoantibody Test Required: ANA titer >=1:80 or anti-ds DNA >=30 IU/mL
SELENA-SLEDAI Score Required: >= 6
Reauthorization SELENA-SLEDAI Score Required: N/A
Patient Exclusion Criteria Documented in Policy: 1 of Excluded for patients receiving other biologic therapies;Excluded for patients with HIV, Hepatitis B, or Hepatitis C virus infection
Reauthorization Requirements Documented in Policy: 3 of Improvement in disease activity;No evidence of active central nervous system lupus;No evidence of severe active lupus nephritis
Does Policy Include Excluded Indications: Yes
- Step Therapy: Systemic Lupus Erythematosus (SLE):
ST Single Generic
|