Anthem Blue Cross (HMO, PPO, EPO)
Xalkori (crizotinib)
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: NSCLC ALK+ OR ROS1+ Disease:
    Documented Diagnosis: Yes
    Duration: 1 year(s)

    NSCLC cMET Mutation:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 1 year(s)

  • Quantity Limit: 4 capsules per 1 day(s).
  • Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location; 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;
  • NSCLC ALK+ OR ROS1+ Disease:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    NSCLC cMET Mutation:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • PA Applies