- Orally administered anticancer medication.
- Prior Authorization: Breast Cancer: gBRCA, Breast Cancer: Triple Negative, Metastatic Prostate Cancer, Pancreatic Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Ovarian Cancer: Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
- Breast Cancer: gBRCA, Breast Cancer: Triple Negative, Metastatic Prostate Cancer, Pancreatic Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Ovarian Cancer: Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: Payer Specific
Diagnosis Types: 3 of advanced ovarian cancer;deleterious or suspected deleterious germline and/or somatic BRCA mutation;Disease progression on three or more prior lines of chemotherapy;epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance treatment after a complete or partial response to platinum-based chemotherapy;persistent or recurrent disease
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