Anthem Blue Cross (HMO, PPO, EPO)
Xofigo (radium Ra 223 dichloride)
Drugs for Cancer : Drugs for Cancer
  • PA Applies
  • Metastatic Prostate Cancer:
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialty Pharmacy Provider(s): 1 of Accredo Health Group, Inc.;Apothecary By Design;Circle Care;The Pharmacy at Maine Medical Center
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • 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;
  • Prior Authorization: Metastatic Prostate Cancer:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 1 year(s)