- Prior Authorization: Breast Cancer: HR+ (HER2-):
Duration: 1 year(s)
Breast Cancer: HR+ (HER2+), Soft Tissue Sarcoma:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Breast Cancer: HR+ (HER2-):
Duration: 1 year(s)
Breast Cancer: HR+ (HER2+):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Soft Tissue Sarcoma:
Duration: 1 year(s)
Reauthorization Required: No
Medical Test Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 3 of as a single agent;Recurrent or metastatic disease;Soft tissue sarcoma
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: Yes
- Step Therapy: Soft Tissue Sarcoma:
ST Multiple Generics
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- PA Applies
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