Anthem Blue Cross (HMO, PPO, EPO) |
Symdeko (tezacaftor-ivacaftor) |
Drugs for the Lungs : Drugs for Cystic Fibrosis |
- Cystic Fibrosis (CF):
Age Requirement: >= 6
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Documented Mutation in the CFTR Gene: Yes
Documented Homozygous F508del Mutation in the CFTR Gene: Yes
Pseudomonas Aeruginosa Culture Required: No
Baseline FEV1 Value (percent predicted): N/A
FEV1 ImprovementMaintenance for Reauthorization: No
Liver Function Test Required: No
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: Cystic Fibrosis (CF):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 1 year(s)
Reauthorization Required: Yes
- PA Applies
- Quantity Limit: 1 pack per 28 day(s).
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