| Anthem Blue Cross (HMO, PPO, EPO) |
| Mylotarg (gemtuzumab ozogamicin) |
| Drugs for Cancer : Drugs for Cancer |
- 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;
- Step Therapy: Acute Myeloid Leukemia:
ST Multiple Generics
- PA Applies
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Acute Myeloid 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
Quantity Limit: N/A
Diagnosis Types: All FDA-approved indications
Excludes Coverage in Maintenance Setting: No
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