- Cervical Cancer, NSCLC Systemic Therapy:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Colorectal Cancer: Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis Requirement: Explicitly Documented
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: <= 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Documented Diagnosis: Yes
Specialty Pharmacy is Required: Not Defined
Endometrial Cancer: Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Kidney Cancer: Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: 2 of Chart Notes;Lab Tests
ECOG Score Requirement Included in Policy: N/A
Policy Includes Reference to Coverage for Non Clear Cell Histology: No
If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
Concomitant Use With: 1 of Afinitor (everolimus);Erlotinib;Interferon Alfa
Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO): Age Requirement: >= 18
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
Ovarian Cancer: Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Concomitant Therapy Requirement: 1 of carboplatin and gemcitabine;paclitaxel;paclitaxel and carboplatin;pegylated liposomal doxorubicin;topotecan
Diagnosis Types: 2 of as a single agent;epithelial ovarian, fallopian tube, or primary peritoneal cancer;platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer;platinum-sensitive recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer;Stage III or IV disease following initial surgical resection;Treated with no more than 2 prior chemotherapy regimens
Supporting Documentation Requirements: Chart Notes
Recurrent Glioblastoma: Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
- Quantity Limit: limit maximum 300 ML PER 30 day(s)
- Step Therapy: Gastro: IBS-C:
Step Applies
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