- Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Oncologist;Urologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
- Health Net Approved Indications and Usage Guidelines:
Diagnosis of metastatic castration-resistant prostate cancer
AND
For patients without visceral metastases: Failure or clinically significant adverse effects to Zytiga
- Step Therapy: ST Single Brand
- Anti-Cancer:Maximum $200 copayment per State Law.
- Step Therapy Exists in PA
- Prior Authorization: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
|