Anthem Blue Cross (HMO, PPO, EPO)
Adcetris (brentuximab vedotin)
Drugs for Cancer : Drugs for Cancer
  • PA Applies
  • Prior Authorization: Documented Diagnosis: Yes
    Duration: 1 year(s)

  • Available only through Specialty Pharmacy; Limited access;
    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;
  • CD-30 Mediated Peripheral T-Cell Lymphoma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialty Pharmacy Provider(s): CVS Specialty
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Hodgkin Lymphoma (HL):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Systemic Anaplastic Large Cell Lymphoma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
    Reauthorization Required: No
    Duration of Reauthorization: N/A