Anthem Blue Cross (HMO, PPO, EPO)
Zydelig (idelalisib)
Drugs for Cancer : Drugs for Cancer
  • PA Applies
  • Chronic Lymphocytic Leukemia:
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    Drug Policy Based On: Payer Specific
    Diagnosis Types: 1 of CLL for relapsed/refractory disease;Small Lymphocytic Lymphoma

    Follicular Lymphoma (FL):
    Duration: 1 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)

    Marginal Zone Lymphoma:
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Non Hodgkin Lymphoma (NHL):
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • 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;
  • Quantity Limit: 2 tablets per 1 day(s).
  • Prior Authorization: Chronic Lymphocytic Leukemia:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Follicular Lymphoma (FL):
    Documented Diagnosis: Yes
    Duration: 1 Month(s)
    Reauthorization Required: Yes

    Marginal Zone Lymphoma:
    Documented Diagnosis: Yes

    Non Hodgkin Lymphoma (NHL):
    Documented Diagnosis: Yes
    Duration: 6 Month(s)