| Anthem Blue Cross (HMO, PPO, EPO) |
| Skytrofa (lonapegsomatropin-tcgd) |
| Hormones : Drugs for Growth |
- Prior Authorization: Growth Hormone Deficiency:
Documented Diagnosis: Yes
Age Requirement: >= 1
Reauthorization Required: Yes
- Growth Hormone Deficiency:
Age Requirement: >= 1
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Pediatric Growth Hormone Deficiency (GHD) Requirement(s): 3 of Growth Velocity Required;Pretreatment growth hormone provocative test result(s) (laboratory report or medical record documentation);Weight >= 11.5 kg
Pediatric - GH Stimulation Test: = 2
Pediatric - Pituitary Hormone Deficiency: >= 2
Adult - GHD Stimulation Test: N/A
Adult - Pituitary Hormone Deficiency: N/A
Adult - Duration of Initial Authorization: N/A
Adult - Duration of Reauthorization: N/A
Documented Diagnosis: Yes
- PA Applies
- Quantity Limit: 8 cartridges per 28 day(s).
- 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;
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