| Anthem Blue Cross (HMO, PPO, EPO) |
| Apidra SoloStar (insulin glulisine U-100) |
| Hormones : Drugs for Diabetes |
- ASCVD:
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
ASCVD - Pooled Cohort Risk Assessment: N/A
Baseline LDL-C Level to Initiate Therapy (% reduction): N/A
Baseline LDL-C Level to Initiate Therapy (mgdL): N/A
Concomitant therapy required with Bile acid sequestrant or niacin: No
Concomitant therapy required with ezetimibe: No
Concomitant therapy required with maximally tolerated statin: No
Documentation Period of LDL-C Levels: N/A
History of CVD presumed to be of Atherosclerotic origin: No
LDL-C Level for Reauthorization (mgdL): N/A
LDL-C Level for Reauthorization (% reduction): N/A
Lifestyle modifications required: No
Duration of Statin Step Failure: N/A
Duration of Ezetimibe Step Failure: N/A
Ezetimibe Step is Optional: No
LDL-C Goal for Optional Ezetimibe Step (% reduction): N/A
Statin Intolerance Defined: No
PushTronex MUST be used after Syringe or Sureclick: No
HeFH:
Unspecified PA: Yes
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Concomitant therapy required with Bile acid sequestrant or niacin: No
Concomitant therapy required with ezetimibe: No
Concomitant therapy required with maximally tolerated statin: No
Lifestyle modifications required: No
Diagnosis verbiage includes genetic testing ( LDLR, ApoB, PCSK9 or ARH mutations): No
Diagnosis verbiage includes Simon Broome criteria: No
Diagnosis verbiage includes WHODutch Lipid Network Criteria: No
Diagnosis verbiage includes US MEDPED criteria: No
Ezetimibe Step is Optional: No
Statin Intolerance Defined: No
PushTronex MUST be used after Syringe or Sureclick: No
HoFH:
Unspecified PA: Yes
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Diagnosis verbiage includes presence of cutaneous or tendon xanthomas before age 10: No
Diagnosis verbiage includes evidence of HeFH in both parents: No
Concomitant therapy required with Bile acid sequestrant or niacin: No
Concomitant therapy required with ezetimibe: No
Concomitant therapy required with maximally tolerated statin: No
Lifestyle modifications required: No
PushTronex MUST be used after Syringe or Sureclick: No
- Cystic Fibrosis (CF):
Age Requirement: >= 6
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of CF Specialist;Infectious Disease Specialist;Pulmonologist
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
Documented Mutation in the CFTR Gene: No
Documented Homozygous F508del Mutation in the CFTR Gene: No
Pseudomonas Aeruginosa Culture Required: Yes
Baseline FEV1 Value (percent predicted): N/A
FEV1 ImprovementMaintenance for Reauthorization: No
Liver Function Test Required: No
- Spinal Muscular Atrophy (SMA):
Age Requirement: <= 2
Duration: 4 week(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Neurologist
Reauthorization Required: No
Duration of Reauthorization: N/A
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;
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