| Anthem Blue Cross (HMO, PPO, EPO) |
| Berinert (C1 esterase inhibitor) |
| Drugs for the Blood : Drugs for the Blood |
- Prior Authorization: Hereditary Angioedema (HAE):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 5
Duration: 1 year(s)
- Hereditary Angioedema (HAE):
Age Requirement: >= 5
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Type(s): Treatment of Acute HAE Attacks
HAE Type: Unspecified
Documented Lab Values: 2 of Low C1-INH Antigenic Level;Low C1-INH Functional Level;Low C4 Level
History of Moderate or Severe Attacks: Yes
- 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;
- Quantity Limit: 24 vials per 30 day(s).
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