Anthem Blue Cross (HMO, PPO, EPO)
Bendeka (bendamustine)
Drugs for Cancer : Drugs for Cancer
  • 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;
  • PA Applies
  • Chronic Lymphocytic 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
    Diagnosis Types: 1 of Chronic Lymphocytic Leukemia;Small Lymphocytic Lymphoma

    Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Marginal Zone Lymphoma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Multiple Myeloma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: NCCN Guidelines
    ECOG Score Requirement in Policy: N/A
    ECOG status <=2: No
    Diagnosis Types: Other recommended regimens for previously treated MM bendamustine/bortezomib/dexamethasone;Other recommended regimens for previously treated MM: Bendamustine/Lenalidomide/Dexamethasone
    Policy Allows for Use as Combination Therapy: No
    Policy Allows for Use Monotherapy Therapy: No

    Non Hodgkin Lymphoma (NHL):
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No

  • Prior Authorization: Chronic Lymphocytic Leukemia, Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Marginal Zone Lymphoma, Multiple Myeloma:
    Documented Diagnosis: Yes
    Duration: 1 year(s)

    Non Hodgkin Lymphoma (NHL):
    Documented Diagnosis: Yes