| Anthem Blue Cross (HMO, PPO, EPO) |
| Daurismo (glasdegib) |
| Drugs for Cancer : Drugs for Cancer |
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Step Therapy: Acute Myeloid Leukemia:
ST Multiple Generics
- 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; Split Fill;
- PA Applies
- Acute Myeloid 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
Quantity Limit: N/A
Diagnosis Types: All FDA-approved indications
Excludes Coverage in Maintenance Setting: No
- Quantity Limit: 1 tablet per 1 day(s).
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