CurrentAnthemPolicy N/A

Prior Authorization (PA) Form — Sickle Cell Disease Drugs

A prior authorization form and requirements for select sickle cell disease medications for Anthem HealthKeepers Plus Medicaid in Virginia; intended for prescribers requesting PA for members. Preferred drugs Droxia, Endari, and Siklos (age 2-17) do not require PA.

Policy Summary

PayerAnthem

PolicyPrior Authorization (PA) Form — Sickle Cell Disease Drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed PA form with required member, prescriber, drug, diagnosis information and supporting documentation (prior therapy, VOC history, age, and medical necessity) to request authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsinitial approval duration

12 monthsrenewal approval duration

>=2 VOCsAdakveo requirement: vaso-occlusive crises

3 monthsminimum hydroxyurea trial before Adakveo

Droxia/Endari/Siklos (2-17)Preferred drugs no PA

Coverage Criteria for Sickle Cell Disease Medications

inv-01: Initial Therapy - General

Covered when ALL of the following are met for initial approval (six months):

Initial PA general criteria: 1) Drug prescribed by or in consultation with an oncologist, hematologist, or sickle cell specialist; 2) Member has diagnosis of sickle cell disease presenting as one of: HbSS, HbSC, HbS β0-thalassemia, or HbS β+-thalassemia; 3) Medication and dose are appropriate for the member's age or other conditions per the FDA-approved product labeling.

Supported by checklist items 1-3 on the PA form

inv-02: Adakveo initial criteria

For Adakveo initial approval (additional requirements):

Adakveo initial: 4) Member had an insufficient response to a minimum three-month trial of hydroxyurea unless hydroxyurea is contraindicated or not tolerated; AND 5) Member experienced two or more vaso-occlusive crises (VOCs) in the previous year despite hydroxyurea therapy.3 months; >=2 VOCs in prior year

Policy Summary

PayerAnthem

PolicyPrior Authorization (PA) Form — Sickle Cell Disease Drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-03: Product-specific age and prior therapy checks

Product-specific age and medical necessity items:

Siklos (hydroxyurea): Siklos does not require prior authorization for ages 2-17. If the member is 18 years of age or older, the PA form asks whether the brand Siklos is medically necessary and requests an explanation if so.age 18

See checklist items 6-7

Xromi (hydroxyurea solution): Xromi requires that the member be 2 years of age or older; the PA form also asks whether the solution formulation is medically necessary and requests an explanation if yes.age >=2

See checklist items 8-9

Endari / generic glutamine packet: For a generic glutamine powder packet, the PA form asks whether the member had an insufficient response to a minimum three-month trial of brand-name Endari for initial approval.

See checklist item 10

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for selected sickle cell drugs. Use one PA form per member. If the PA form is incomplete, incorrect, or illegible the PA process may be delayed. Submission of documentation does not guarantee coverage.

Preferred drugs Droxia®, Endari®, and Siklos® (if age 2–17) do not require a PA.
Completed PA form may be faxed to 844-512-7020.

Step Therapy

Hydroxyurea Trial Prior to Adakveo

For initial approval of Adakveo®, the member must have had an insufficient response to a minimum three-month trial of hydroxyurea unless hydroxyurea is contraindicated or the member is intolerant. For renewal, document continued clinical benefit (decrease in vaso-occlusive crises frequency, reduced hospitalizations, or reduced VOC severity).

Adakveo®: insufficient response to ≥3 months of hydroxyurea (unless contraindicated/intolerant) required for initial approval.
Renewal for Adakveo®: document clinical response compared to pre-treatment baseline (reduced VOCs, hospitalizations, or severity).

Documentation Required

Required Documentation

The PA form must include member, prescriber, drug, and diagnosis/medical information. Prescriber signature and supporting documentation are required. Please answer all applicable clinical questions on the form; incomplete forms will delay the PA process.

Member information: last name, first name, Medicaid ID, date of birth, weight (kg).
Prescriber information: last name, first name, NPI, phone, fax, and prescriber signature with date.
Drug information: drug name/form (Adakveo®, Siklos® if >18, glutamine powder), strength, dosing frequency, length of therapy, quantity per day.
Diagnosis/medical information: confirmation of sickle cell genotype (HbSS, HbSC, HbS β0‑thalassemia, HbS β+‑thalassemia), provider specialty (oncologist/hematologist/sickle cell specialist), age‑ and dose‑appropriate medication per FDA labeling, prior therapies (hydroxyurea, Endari®), number of VOCs in prior year, and explanations when brand or formulation is claimed medically necessary.

Denial Risk

Form Completeness and Coverage Caveat

Incomplete or incorrect forms may delay the PA process. Use one form per member. Submission of documentation does not guarantee coverage.

If information is not complete, correct, or legible the PA process can be delayed.
One form per member; incomplete forms will delay PA.
Submission does not guarantee coverage; verification may be required.

OpenPayer

Prior Authorization (PA) Form — Sickle Cell Disease Drugs

Coverage Criteria for Sickle Cell Disease Medications

Provider Actions, Prior Authorization, and Documentation

Background

Definitions and Eligible Genotypes