CurrentAnthemPolicy N/A

Request for Prior Authorization — Sickle Cell Agents (Endari / L-glutamine)

A fillable prior authorization (PA) request form used by Anthem Medicaid plans (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging) to request PA for Endari (L‑glutamine) and related indications including sickle cell disease, short bowel syndrome, mucositis following chemotherapy, and prophylaxis of chemotherapy-induced peripheral neuropathy.

Policy Summary

PayerAnthem

PolicyRequest for Prior Authorization — Sickle Cell Agents (Endari / L-glutamine)

Policy CodePolicy N/A

Change TypeForm/administrative (no material clinical changes)

Effective Date

Next Review Date

Key ActionPrescribing provider must complete the form in its entirety and fax to the Prior Authorization of Benefits Center at 844-864-7860 (retail) or 888-209-7838 (medical injectable).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — this is a fillable PA request form with required fields and instructions.

3Primary Indication Categories Listed

5Explicit Form Completion Requirements

30Maximum Daily Dose (g)

Policy summary

This is an Anthem Medicaid prior authorization (PA) request form for L‑glutamine (Endari) covering multiple indications: sickle cell disease, short bowel syndrome, and mucositis following chemotherapy / prophylaxis of chemotherapy‑induced peripheral neuropathy. The form documents required clinical information and specialist involvement for PA processing, including patient age and diagnosis details for sickle cell disease, documentation of concurrent hydroxyurea therapy or intolerance/contraindication, indication‑specific questions for short bowel syndrome and oncology‑related uses, and a maximum daily dose limit of ≤ 30 grams (6 × 5 g packets).

Prior authorization criteria (form fields)

Endari (L-glutamine) Prior Authorization Requirements

Form fields indicate criteria to be provided for initiation or continuation of therapy for specified indications; copy of form text preserved.

ALL of the following

Requested therapy: Initiation of therapy or Continuation of therapy (refill) indicated on form
Sickle cell diagnosis and age: Member is 5 years of age or older with diagnosis of sickle cell disease (examples listed: homozygous hemoglobin S, sickle hemoglobin C disease, sickle beta0 thalassemia, sickle beta+ thalassemia)>= 5 years
Prescriber specialty: Prescribed by, or in consultation with, a hematologist or other prescriber specialized in the treatment of sickle cell disease
Documentation of specialist involvement required
Hydroxyurea status
- Currently on hydroxyurea: Member is currently receiving hydroxyurea therapy
  Document concurrent hydroxyurea therapy
- Hydroxyurea intolerance/contraindication: Member has history of intolerance or contraindications to hydroxyurea therapy
  Document rationale for intolerance or contraindication
Exclusion / contraindication questions
- Short bowel syndrome selection: Short bowel syndrome (see questions 7 and 8)
  If selected, complete short bowel syndrome specific questions
- Mucositis following chemotherapy selection: Mucositis following chemotherapy (see question 9)
  If selected, see oncologist requirement
- Chemotherapy-induced peripheral neuropathy selection: Prophylaxis of peripheral neuropathy due to oxaliplatin or high-dose paclitaxel use (see question 9)
  If selected, see oncologist requirement
Initiation-only additional requirement for sickle cell
- Two VOCs while on hydroxyurea: Initiation only: Member experienced two sickle cell-related vaso-occlusive crisis events within the previous 12 months while concurrently receiving hydroxyurea therapy>= 2 VOCs in prior 12 months
  Dates of events to be provided
- Initiation alternative - HU intolerance/contraindication: Initiation only alternative: Member has intolerance or contraindication to hydroxyurea therapy
  Documents alternative pathway for initiation
Short bowel syndrome specific requirements (if diagnosed)
- Concurrent growth hormone: If member is diagnosed with short bowel syndrome, is member using recombinant human growth hormone concurrently with L-glutamine therapy? (Yes/No; if no, provide rationale)
  Form asks for yes/no and rationale if not using
- Short bowel prescriber specialty: Prescribed by, or in consultation with, a gastroenterologist or other prescriber specialized in the treatment of short bowel syndrome
  Specialist documentation required
Mucositis / chemotherapy peripheral neuropathy requirements
- Oncologist prescriber: If member is diagnosed with mucositis following chemotherapy and/or prophylaxis of peripheral neuropathy due to oxaliplatin or high-dose paclitaxel use, prescribed by, or in consultation with, an oncologist
  Specialist documentation required
Dose limit: Requested dose does not exceed 30 grams (6 x 5 gm packets) daily for all above indications<= 30 grams daily
Requests exceeding this dose may not meet PA requirements

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What the prescriber must do

Documentation Required

Form completion and submission

Prescribing provider must complete the form in its entirety and fax to the Prior Authorization of Benefits Center. Fax numbers: 844-864-7860 (retail) or 888-209-7838 (medical injectable). The form must be completed by the prescribing provider and all sections completed or the request will be returned.

Prior Authorization

Retroactive PA handling

Submit retroactive PA requests (dates of service prior to eligibility determination but within established eligibility timelines) separately from current PA requests. Retro requests are those with dates of service prior to 30 calendar days of submission; current PA requests are dates of service 30 calendar days or less and going forward.

Documentation Required

Specialist consultation requirement

Provide documentation that the prescription is by, or in consultation with, an appropriate specialist for the indicated diagnosis.

Sickle cell disease: hematologist
Short bowel syndrome: gastroenterologist
Mucositis following chemotherapy or chemotherapy-related peripheral neuropathy: oncologist

Documentation Required

Hydroxyurea therapy status

Document whether the member is currently receiving hydroxyurea therapy or has a history of intolerance or contraindication to hydroxyurea. For initiation requests for sickle cell indication, include dates of two vaso-occlusive crises in the prior 12 months if applicable.

Billing Rule

Dose limit

Requested dose must not exceed 30 grams per day (equivalent to 6 × 5 g packets). Requests exceeding this maximum may not meet prior authorization requirements.

OpenPayer

Request for Prior Authorization — Sickle Cell Agents (Endari / L-glutamine)

Policy summary

Prior authorization criteria (form fields)

What the prescriber must do

Form logistics and handling

Document revisions