Anthem Blue Cross (HMO, PPO, EPO)
Xgeva (denosumab)
Hormones : Drugs for Menopause and Bone Loss
  • Hepatocellular Carcinoma:
    Age Requirement: >= 18
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Oncologist
    Duration of Reauthorization: = 1 plan year
    Diagnosis Types: 3 of All FDA-approved indications;for adults who received previous treatment with sorafenib;Hepatocellular Cancer;NCCN recommended level 2a-b or better
    ECOG Score Requirement Included in Policy: N/A
    Child-Pugh Score Required for Treatment: Class A (5-6)

    Kidney Cancer:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    Drug Policy Based On: FDA Approved Indications
    Supporting Documentation Requirements: 2 of Chart Notes;Lab Tests;Medication History
    ECOG Score Requirement Included in Policy: N/A
    Policy Includes Reference to Coverage for Non Clear Cell Histology: No
    If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
    Concomitant Use With: 1 of CYP3A4 inducer;Opdivo

    Thyroid Carcinoma:
    Age Requirement: >= 12
    Duration: 12 Month(s)
    Specialist Required: Yes

  • Quantity Limit: 1 bottle per 30 day(s).
  • Prior Authorization: Assisted Reproductive Technology (ART):
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Gender Requirement: Female
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Step Therapy: ST_APPLIES

  • 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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