- Prior Authorization: Urothelial/Bladder Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Anti-Cancer: Maximum $200 copayment per State Law.
- Urothelial/Bladder Cancer:
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: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 3 of FGFR3 or FGFR2 mutation-positive as detected by an FDA approved test;Locally advanced or metastatic urothelial carcinoma;Progressed during or following prior platinum-containing chemotherapy or checkpoint inhibitor therapy;Recurrent disease
ECOG Score Requirement Included in Policy: N/A
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