Prior authorization for sickle cell agents (Endari/L-glutamine)
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Form and prior authorization requirements for L-glutamine (Endari) and related sickle cell therapy requests for members served by Anthem Blue Cross and Blue Shield programs listed; intended for prescribing providers requesting PA for initiation or continuation of therapy.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial or continuation therapy criteria
Covered when ALL of the following are met for sickle cell indication:
Other labeled indications
Additional indication-specific requirements (short bowel syndrome; mucositis/prophylaxis of chemotherapy-induced peripheral neuropathy):
The completed prior authorization form and any accompanying documents may contain confidential health information that is legally privileged. The information is intended only for the use of the authorized recipient and must not be disclosed to any other party except as required by law or regulation. If you are not the intended recipient, do not disclose, copy, distribute, or act on the information; instead notify the sender and arrange for return or destruction of the documents. Do not use or disclose Protected Health Information (PHI) for individuals you are not treating or who are not enrolled in your practice, including PHI transmitted by mail, fax, email, or other electronic means.
The form must be fully completed and signed by the prescribing provider. All sections must be completed; incomplete or unsigned requests will be returned and may delay prior authorization processing.
Coding and Dosing
Provider Actions and Requirements
Prior Authorization Required
Prior authorization is required for both initiation and continuation (refill) of Endari (L‑glutamine). Indicate whether the request is for initiation or continuation on the PA form and include all required clinical documentation to support the requested service.
- Prior authorization fax numbers: 844-864-7860 (retail) or 888-209-7838 (medical injectable)
- Specify: Initiation of therapy OR Continuation of therapy (refill)
Hydroxyurea Requirement or Intolerance
Document whether the member is currently receiving hydroxyurea therapy, or provide clear documentation of intolerance or contraindication to hydroxyurea. For initiation requests, if the member experienced vaso-occlusive crisis events while on hydroxyurea, include dates and supporting records; if hydroxyurea is not appropriate, include clinical rationale and relevant history.
- Member is currently receiving hydroxyurea therapy: Yes / No
- If intolerance/contraindication to hydroxyurea, provide clinical documentation and rationale
- For initiation: document two vaso-occlusive crisis events in prior 12 months while on hydroxyurea, or documented intolerance/contraindication (include dates)
Form Completion and Submission
Complete the PA form in its entirety. The prescribing provider must complete and sign the form; include prescriber name, state license number, NPI, prescriber signature, and a return fax or phone number. Include patient identifiers and relevant dates of service. Fax completed form to the Prior Authorization of Benefits Center at 844-864-7860 (retail) or 888-209-7838 (medical injectable).
- Required prescriber fields: name, state license number, NPI, signature, return fax number, return phone number
- Include patient identifiers and dates of service (for retroactive PA, submit separate with dates prior to 30 calendar days)
- Fax numbers: 844-864-7860 (retail) or 888-209-7838 (medical injectable)
Incomplete or Unsigned Request
Incomplete or unsigned PA requests will be returned and will delay or prevent authorization. Ensure every section of the form is filled out and the prescriber signature is present prior to submission.
- Unsigned or incomplete forms will be returned to the provider
- Retroactive PA requests require separate submission when dates of service are more than 30 calendar days prior to submission
Background
L‑glutamine (Endari) is indicated as a disease‑modifying therapy for certain patients with sickle cell disease to reduce the incidence of vaso‑occlusive crises. The prior authorization request must document the member’s diagnosis of sickle cell disease (including genotypes such as HbSS, HbSC, sickle beta0 thalassemia, or sickle beta+ thalassemia), age, current hydroxyurea status or documented intolerance/contraindication to hydroxyurea, and a history of vaso‑occlusive crisis events when applicable.
For initiation of Endari, the form requires that the member be 5 years of age or older and have experienced two sickle cell–related vaso‑occlusive crises within the prior 12 months while receiving hydroxyurea (unless hydroxyurea is not tolerated or contraindicated). Requests must also specify dosing that does not exceed 30 grams per day and be prescribed by, or in consultation with, a hematologist or other clinician experienced in treating sickle cell disease.
Definitions
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