| Anthem Blue Cross (HMO, PPO, EPO) |
| Kisqali (600 MG Dose) (ribociclib) |
| Drugs for Cancer : Drugs for Cancer |
- Step Therapy: Cervical Dystonia, Limb Spasticity:
ST Single Brand
Chronic Sialorrhea:
ST Single Generic
Migraine Prevention:
ST Multiple Generics
- Prior Authorization: Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 5
Duration: 1 plan year
Reauthorization Required: Yes
- Quantity Limit: 5 tablets per 1 day(s).
- Available only through Specialty Pharmacy;
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: PA Required
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