- Breast Cancer: gBRCA, Metastatic Prostate Cancer, Pancreatic Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Breast Cancer: Triple Negative:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): CVS Specialty
Reauthorization Required: No
Duration of Reauthorization: N/A
Ovarian Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
Concomitant Therapy Requirement: bevacizumab (Avastin)
Diagnosis Types: 3 of advanced ovarian cancer;deleterious or suspected deleterious germline and/or somatic BRCA mutation;epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance treatment after a complete or partial response to platinum-based chemotherapy;Patients who have been treated with three or more prior lines of chemotherapy;Recurrent disease
Supporting Documentation Requirements: 2 of BRCA mutation as detected by an approved FDA laboratory test;Homologous recombination deficiency (HRD) testing
- PA Applies
- Prior Authorization: Breast Cancer: gBRCA, Breast Cancer: Triple Negative, Metastatic Prostate Cancer, Pancreatic Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Ovarian Cancer:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Quantity Limit: 4 tablets per 1 day(s).
- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location; Limited access;
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;
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