Anthem Blue Cross (HMO, PPO, EPO)
Gleevec (imatinib)
Drugs for Cancer : Drugs for Cancer
  • Quantity Limit: 2 tablets per 1 day(s).
  • Acute Lymphoblastic Leukemia:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: Payer Specific
    Diagnosis Types: Ph+ ALL
    ECOG Score Requirement Included in Policy: N/A
    Specialty Pharmacy is Required: Not Defined

    Aggressive Systemic Mastocytosis (ASM), Chronic Myelogenous Leukemia, Gastrointestinal Stromal Tumor:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • Prior Authorization: Documented Diagnosis: Yes
    Duration: 1 year(s)

  • PA Applies
  • Step Therapy: ST Single Generic

  • 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;